1730237512 NPI number — EILEEN E. WATROUS-TRAN MD

Table of content: EILEEN E. WATROUS-TRAN MD (NPI 1730237512)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730237512 NPI number — EILEEN E. WATROUS-TRAN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATROUS-TRAN
Provider First Name:
EILEEN
Provider Middle Name:
E.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

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:
1730237512
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1761 CHATHAM CT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLAREMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91711-3017
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
909-593-2528
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1800 N LAKE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PASADENA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91104-1228
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-993-1262
Provider Business Practice Location Address Fax Number:
626-204-0086
Provider Enumeration Date:
01/08/2007

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:  G63863 , 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: 00G638630 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".