Provider Demographics
NPI:1528150901
Name:DOLBERG, BEVERLY K (MD)
Entity type:Individual
Prefix:DR
First Name:BEVERLY
Middle Name:K
Last Name:DOLBERG
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 1:1593 GOLD CUP CT
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2767
Mailing Address - Country:US
Mailing Address - Phone:909-794-1898
Mailing Address - Fax:909-794-1898
Practice Address - Street 1:VA LOMA LINDA
Practice Address - Street 2:11201 BENTON STREET
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92357-0001
Practice Address - Country:US
Practice Address - Phone:909-583-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD055567L207R00000X
DEC1-0004697207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAG09465Medicare UPIN
PAD0785709Medicare ID - Type Unspecified