Healthcare Provider Details

I. General information

NPI: 1265744718
Provider Name (Legal Business Name): RAY LENGVILAS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2010
Last Update Date: 08/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

IV. Provider business mailing address

742 W HIGHLAND AVE
SAN BERNARDINO CA
92405-3839
US

V. Phone/Fax

Practice location:
  • Phone: 909-881-7320
  • Fax:
Mailing address:
  • Phone: 909-881-7320
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberR71994
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA123121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: