Basic Information
| Provider Information | |||||||||
| NPI: | 1952020315 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DESERT VALLEY MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16850 BEAR VALLEY RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923955795 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602418000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 12998 HESPERIA RD STE 101 | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923958317 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609552828 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2022 | ||||||||
| LastUpdateDate: | 10/13/2022 | ||||||||
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| AuthorizedOfficialLastName: | BHATIA | ||||||||
| AuthorizedOfficialFirstName: | KAVITHA | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7602418000 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | DESERT VALLEY MEDICAL GROUP, INC | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 10/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.