1508161449 NPI number — MS. ELSA VICTORIA BERMUDEZ R.D.

Table of content: MS. ELSA VICTORIA BERMUDEZ R.D. (NPI 1508161449)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508161449 NPI number — MS. ELSA VICTORIA BERMUDEZ R.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BERMUDEZ
Provider First Name:
ELSA
Provider Middle Name:
VICTORIA
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
R.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JOHNSON
Provider Other First Name:
ELSA
Provider Other Middle Name:
VICTORIA
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
R.D.
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1508161449
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/25/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4159 NEWPORT CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN BERNARDINO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92404-1436
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-425-6273
Provider Business Mailing Address Fax Number:
909-425-7069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3102 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PATTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92369-7813
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-425-6273
Provider Business Practice Location Address Fax Number:
909-425-7069
Provider Enumeration Date:
01/25/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  1037396 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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