Provider Demographics
NPI:1427125871
Name:CESPON, POLIENO A (MD)
Entity type:Individual
Prefix:
First Name:POLIENO
Middle Name:A
Last Name:CESPON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1825 VIA DEL REY ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-4151
Mailing Address - Country:US
Mailing Address - Phone:323-344-0018
Mailing Address - Fax:323-344-0018
Practice Address - Street 1:1825 VIA DEL REY ST
Practice Address - Street 2:
Practice Address - City:SOUTH PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-4151
Practice Address - Country:US
Practice Address - Phone:323-344-0018
Practice Address - Fax:323-344-0018
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA22356207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A223560Medicaid
CA0A223560Medicaid