Healthcare Provider Details

I. General information

NPI: 1871721647
Provider Name (Legal Business Name): DENISE RENEE PERSICHINO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2009
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10737 LAUREL ST STE 230
RANCHO CUCAMONGA CA
91730-7659
US

IV. Provider business mailing address

303 E VANDERBILT WAY
SAN BERNARDINO CA
92415-0026
US

V. Phone/Fax

Practice location:
  • Phone: 909-989-5556
  • Fax: 909-347-8916
Mailing address:
  • Phone: 909-388-0810
  • Fax: 909-890-0281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number20A9889
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: