Individual
HA LE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
400 N PEPPER AVE, COLTON, CA 92324-1801
(909) 580-1520
(909) 580-1561
Mailing address
400 N PEPPER AVE, COLTON, CA 92324-1801
(909) 580-1520
(909) 580-1561
Taxonomy
Speciality
Code
Description
License number
State
2085N0904X
Nuclear Radiology Physician
G80374
CA
2085R0202X
Diagnostic Radiology Physician
Primary
G80374
CA
2085R0204X
Vascular & Interventional Radiology Physician
G80374
CA
2085U0001X
Diagnostic Ultrasound Physician
G80374
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
00G803740
—
CA
01
—
G80374
STATE LICENSE
CA
Enumeration date
09/20/2006
Last updated
01/20/2009
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