Healthcare Provider Details

I. General information

NPI: 1851408116
Provider Name (Legal Business Name): GENEROSO SANTOS NERY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 08/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 E FOOTHILL BLVD SUITE 135
UPLAND CA
91786-4079
US

IV. Provider business mailing address

1183 E FOOTHILL BLVD SUITE 135
UPLAND CA
91786-4079
US

V. Phone/Fax

Practice location:
  • Phone: 909-931-1368
  • Fax: 909-931-1372
Mailing address:
  • Phone: 909-931-1368
  • Fax: 909-931-1372

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA31007
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: