Basic Information
| Provider Information | |||||||||
| NPI: | 1225038342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CHIRIBOGA | ||||||||
| FirstName: | DOUGLAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094699494 | ||||||||
| FaxNumber: | 9094692120 | ||||||||
| Practice Location | |||||||||
| Address1: | 1770 N ORANGE GROVE AVE STE 101 | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917673027 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094699494 | ||||||||
| FaxNumber: | 9094692120 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A56038 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BC4898536 | 01 | CA | DEA NUMBER | OTHER | 1225038342 | 05 | CA | MEDICAID | A560038 | 01 | CA | MEDICAL LICENSE | OTHER |