1700124161 NPI number — BERNARDUS GANI SUGIARTO KARTONO WINARDI MD

Table of content: BERNARDUS GANI SUGIARTO KARTONO WINARDI MD (NPI 1700124161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700124161 NPI number — BERNARDUS GANI SUGIARTO KARTONO WINARDI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KARTONO WINARDI
Provider First Name:
BERNARDUS
Provider Middle Name:
GANI SUGIARTO
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:
1700124161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/21/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2050 S BLOSSER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA MARIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93458-7310
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-361-8028
Provider Business Mailing Address Fax Number:
805-361-8097

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 W CENTRAL AVE
Provider Second Line Business Practice Location Address:
SUITE 201
Provider Business Practice Location Address City Name:
LOMPOC
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93436-2805
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-737-1169
Provider Business Practice Location Address Fax Number:
805-737-1772
Provider Enumeration Date:
01/19/2013

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: 282N00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: A135298 , 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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