Provider Demographics
NPI:1972006526
Name:BARRERA, SEVERINO G
Entity type:Individual
Prefix:
First Name:SEVERINO
Middle Name:G
Last Name:BARRERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 PALOMAR ST STE B3
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91911-2627
Mailing Address - Country:US
Mailing Address - Phone:619-525-2469
Mailing Address - Fax:
Practice Address - Street 1:895 PALOMAR ST STE B3
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91911-2627
Practice Address - Country:US
Practice Address - Phone:619-525-2469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-09
Last Update Date:2018-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
823336364OtherTIN