Provider Demographics
NPI:1699717306
Name:RADA, RENATO G (MD)
Entity type:Individual
Prefix:
First Name:RENATO
Middle Name:G
Last Name:RADA
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 1:625 FAIR OAKS AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-5801
Mailing Address - Country:US
Mailing Address - Phone:626-346-2455
Mailing Address - Fax:626-639-3005
Practice Address - Street 1:190 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3658
Practice Address - Country:US
Practice Address - Phone:909-882-4968
Practice Address - Fax:877-860-7268
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37714207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A377140Medicaid
CAP01288545/DU4034OtherRAILROAD MEDICARE- SAN BERNARDINO
CA00A377140OtherMEDI-CAL
CA00A377140OtherMEDI-CAL
CA00A377140Medicare PIN
CAGC884YMedicare PIN
CAWA37714OMedicare PIN
CACA109379 EFF 8/21/13Medicare PIN
CAP01288545/DU4034OtherRAILROAD MEDICARE- SAN BERNARDINO
A85041Medicare UPIN
CAWA37714MMedicare PIN