Healthcare Provider Details

I. General information

NPI: 1497040919
Provider Name (Legal Business Name): DEBORSHI ROY MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8906 SAN BERNARDINO RD SUITE104
RANCHO CUCAMONGA CA
91730-8805
US

IV. Provider business mailing address

PO BOX 77365
CORONA CA
92877-0112
US

V. Phone/Fax

Practice location:
  • Phone: 909-466-0847
  • Fax: 909-466-0867
Mailing address:
  • Phone: 951-738-8217
  • Fax: 951-738-0524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberC54320
License Number StateCA

VIII. Authorized Official

Name: MS. KIMBERLY DIANE SWANSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 951-738-8217