Provider Demographics
NPI:1962560896
Name:JOSE D BERGANZA, M.D INC
Entity type:Organization
Organization Name:JOSE D BERGANZA, M.D INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:DALIO
Authorized Official - Last Name:BERGANZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-337-0424
Mailing Address - Street 1:14514 RAMONA BLVD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-3305
Mailing Address - Country:US
Mailing Address - Phone:626-337-0424
Mailing Address - Fax:626-813-9095
Practice Address - Street 1:14514 RAMONA BLVD
Practice Address - Street 2:SUITE 3
Practice Address - City:BALDWIN PARK
Practice Address - State:CA
Practice Address - Zip Code:91706-3305
Practice Address - Country:US
Practice Address - Phone:626-337-0424
Practice Address - Fax:626-813-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA055611207Q00000X
CAA37324207V00000X
CA524415207V00000X
CA557547207V00000X
CAA45608208000000X
CAPA12379208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0080790Medicaid
CAGR0080790Medicaid