Healthcare Provider Details

I. General information

NPI: 1477630580
Provider Name (Legal Business Name): DE ANZA OBSTETRICS AND GYNECOLOGY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 10/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4190 CHICAGO AVE
RIVERSIDE CA
92507-5348
US

IV. Provider business mailing address

PO BOX 1762
COLTON CA
92324-0857
US

V. Phone/Fax

Practice location:
  • Phone: 951-683-2106
  • Fax: 951-683-2105
Mailing address:
  • Phone: 951-683-2106
  • Fax: 951-638-2105

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA38671
License Number StateCA

VIII. Authorized Official

Name: DR. GUILLERMO VALENZUELA
Title or Position: PRESIDENT
Credential:
Phone: 909-580-3470