Healthcare Provider Details

I. General information

NPI: 1093042970
Provider Name (Legal Business Name): PAULUS SANTOSO MD A PROFESSIONAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2009
Last Update Date: 03/04/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6969 BROCKTON AVE SUITE A-B
RIVERSIDE CA
92506-3809
US

IV. Provider business mailing address

6969 BROCKTON AVE SUITE A-B
RIVERSIDE CA
92506-3809
US

V. Phone/Fax

Practice location:
  • Phone: 951-530-8989
  • Fax: 951-530-8877
Mailing address:
  • Phone: 951-530-8989
  • Fax: 951-530-8877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberA85478
License Number StateCA

VIII. Authorized Official

Name: DR. PAULUS LIEM SANTOSO
Title or Position: CEO
Credential: M.D.
Phone: 951-530-8989