Basic Information
| Provider Information | |||||||||
| NPI: | 1801865563 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DHADWAL | ||||||||
| FirstName: | JAGTAR | ||||||||
| MiddleName: | SARUP | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 TOWNE CENTER DR | ||||||||
| Address2: | ADMINISTRATIVE RESOURCES | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917675900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093981550 | ||||||||
| FaxNumber: | 9093981573 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 W BONITA AVE | ||||||||
| Address2: | #250 | ||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917671863 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098686800 | ||||||||
| FaxNumber: | 9098685379 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 02/24/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A47802 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A478020 | 05 | CA | MEDICAID |