Basic Information
| Provider Information | |||||||||
| NPI: | 1447206073 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ADAN | ||||||||
| FirstName: | OLGA | ||||||||
| MiddleName: | M. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12209 | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924232209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097933311 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Practice Location | |||||||||
| Address1: | 10431 LEMON AVE | ||||||||
| Address2: | #N | ||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917373700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094666579 | ||||||||
| FaxNumber: | 9097964158 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/25/2006 | ||||||||
| LastUpdateDate: | 03/04/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G75426 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00G754250 | 05 | CA | MEDICAID |