Healthcare Provider Details

I. General information

NPI: 1427210160
Provider Name (Legal Business Name): JUAN C. BAEZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2008
Last Update Date: 08/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST STE MC-B623A
LOMA LINDA CA
92354-2804
US

IV. Provider business mailing address

12339 HIGH HORSE DR
RANCHO CUCAMONGA CA
91739-9554
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-4013
  • Fax:
Mailing address:
  • Phone: 909-558-4013
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberD77532
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberMD042259
License Number StateDC
# 3
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number0101255919
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberA150446
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: