Provider Demographics
NPI:1104881549
Name:SANSONE, BEVERLY (MD)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:
Last Name:SANSONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9940 TALBERT AVE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-5153
Mailing Address - Country:US
Mailing Address - Phone:714-378-5606
Mailing Address - Fax:714-378-5621
Practice Address - Street 1:9940 TALBERT AVE
Practice Address - Street 2:SUITE 303
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-5153
Practice Address - Country:US
Practice Address - Phone:714-378-5606
Practice Address - Fax:714-378-5621
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2010-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG53820174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist