Healthcare Provider Details

I. General information

NPI: 1003120429
Provider Name (Legal Business Name): BENJAMIN MAURICE KERSHBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2010
Last Update Date: 11/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 S VINEYARD AVE MOB A
ONTARIO CA
91761-7925
US

IV. Provider business mailing address

2150 S STATE COLLEGE BLVD APT. 1076
ANAHEIM CA
92806-0102
US

V. Phone/Fax

Practice location:
  • Phone: 909-724-2554
  • Fax: 909-724-2552
Mailing address:
  • Phone: 310-927-4442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA111594
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: