Basic Information
| Provider Information | |||||||||
| NPI: | 1790746014 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CHOUDHARY | ||||||||
| FirstName: | RANJIV | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 41210 11TH ST W | ||||||||
| Address2: | STE G | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935511447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612741777 | ||||||||
| FaxNumber: | 6612742777 | ||||||||
| Practice Location | |||||||||
| Address1: | 41210 11TH ST W | ||||||||
| Address2: | STE G | ||||||||
| City: | PALMDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 935511447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6612741777 | ||||||||
| FaxNumber: | 6612742777 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2006 | ||||||||
| LastUpdateDate: | 03/14/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A41754 | CA | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 00A417540 | 05 | CA | MEDICAID |