Provider Demographics
NPI:1962693754
Name:SPROUT PEDIATRICS, INC.
Entity type:Organization
Organization Name:SPROUT PEDIATRICS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WEBSTER
Authorized Official - Middle Name:A
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-580-6315
Mailing Address - Street 1:1666 MEDICAL CENTER DR
Mailing Address - Street 2:SUITE 4
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92411-1257
Mailing Address - Country:US
Mailing Address - Phone:909-887-7050
Mailing Address - Fax:
Practice Address - Street 1:1666 MEDICAL CENTER DR
Practice Address - Street 2:SUITE 4
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1257
Practice Address - Country:US
Practice Address - Phone:909-887-7050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty