Healthcare Provider Details

I. General information

NPI: 1700866894
Provider Name (Legal Business Name): MAX VINCO SOLIGUEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1183 E FOOTHILL BLVD SUITE 230
UPLAND CA
91786
US

IV. Provider business mailing address

6246 INDIGO AVE
ALTA LOMA CA
91701-2551
US

V. Phone/Fax

Practice location:
  • Phone: 909-920-9050
  • Fax: 909-920-9057
Mailing address:
  • Phone: 909-466-9160
  • Fax: 909-466-9160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA56150
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: