Healthcare Provider Details

I. General information

NPI: 1801991450
Provider Name (Legal Business Name): COLTON VALLEY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 W VALLEY BLVD
COLTON CA
92324
US

IV. Provider business mailing address

502 W VALLEY BLVD
COLTON CA
92324
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-3202
  • Fax: 909-825-9375
Mailing address:
  • Phone: 909-825-3202
  • Fax: 909-825-9375

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA23744
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WAGIAN SUN
Title or Position: PRESIDENT
Credential: MD
Phone: 909-825-3202