Basic Information
| Provider Information | |||||||||
| NPI: | 1942250873 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESERT VALLEY MEDICAL GROUP, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | PRIMECARE MEDICAL GROUP OF DESERT VALLEY, INC. | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16850 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955794 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602418000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11499 BARTLETT AVE | ||||||||
| Address2: | |||||||||
| City: | ADELANTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923011902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602418000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2006 | ||||||||
| LastUpdateDate: | 04/27/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BHATIA | ||||||||
| AuthorizedOfficialFirstName: | KAVITHA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7602418000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083X0100X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Occupational Medicine | 208D00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | General Practice | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0072097 | 05 | CA | MEDICAID | 4584430010 | 01 | CA | DMERC | OTHER | CC8406 | 01 | CA | RAILROAD MEDICARE | OTHER |