1699717306 NPI number — RENATO G RADA MD

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699717306 NPI number — RENATO G RADA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
RADA
Provider First Name:
RENATO
Provider Middle Name:
G
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699717306
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/29/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
625 FAIR OAKS AVE STE 270
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH PASADENA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91030-5801
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-346-2455
Provider Business Mailing Address Fax Number:
626-639-3005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
190 E HIGHLAND AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN BERNARDINO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92404-3658
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-882-4968
Provider Business Practice Location Address Fax Number:
877-860-7268
Provider Enumeration Date:
06/10/2006

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: 207Q00000X , with the licence number:  A37714 , 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)

  • Identifier: 00A377140 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: P01288545/DU4034 . This is a "RAILROAD MEDICARE- SAN BERNARDINO" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: 00A377140 . This is a "MEDI-CAL" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".