Healthcare Provider Details

I. General information

NPI: 1710539150
Provider Name (Legal Business Name): ALFREDO DANIEL COLON-MARRERO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

IV. Provider business mailing address

11234 ANDERSON ST # MC1516
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6472
  • Fax:
Mailing address:
  • Phone: 909-558-6472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License Number288871
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207RS0012X
TaxonomySleep Medicine (Internal Medicine) Physician
License NumberA209097
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2080S0012X
TaxonomyPediatric Sleep Medicine Physician
License NumberA209097
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: