Healthcare Provider Details

I. General information

NPI: 1962560896
Provider Name (Legal Business Name): JOSE D BERGANZA, M.D INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 01/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14514 RAMONA BLVD SUITE 3
BALDWIN PARK CA
91706-3305
US

IV. Provider business mailing address

14514 RAMONA BLVD SUITE 3
BALDWIN PARK CA
91706-3305
US

V. Phone/Fax

Practice location:
  • Phone: 626-337-0424
  • Fax: 626-813-9095
Mailing address:
  • Phone: 626-337-0424
  • Fax: 626-813-9095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA055611
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA37324
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number524415
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number557547
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA45608
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberPA12379
License Number StateCA

VIII. Authorized Official

Name: DR. JOSE DALIO BERGANZA
Title or Position: PRESIDENT
Credential: M.D
Phone: 626-337-0424