Provider Demographics
NPI:1427488006
Name:TOBIAS MOELLER-BERTRAM, M.D CORP
Entity type:Organization
Organization Name:TOBIAS MOELLER-BERTRAM, M.D CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSITRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:MCDONALD
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:949-783-3600
Mailing Address - Street 1:3857 BIRCH ST.
Mailing Address - Street 2:SUITE 605
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660
Mailing Address - Country:US
Mailing Address - Phone:949-786-3600
Mailing Address - Fax:
Practice Address - Street 1:81812 DR CARREON BLVD
Practice Address - Street 2:SUITE D
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-0607
Practice Address - Country:US
Practice Address - Phone:760-347-7676
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-19
Last Update Date:2013-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA80383208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6888120001Medicare PIN