Basic Information
Provider Information | |||||||||
NPI: | 1609964121 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ALBANO | ||||||||
FirstName: | FELIX | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 685 CARNEGIE DRIVE | ||||||||
Address2: | SUITE 230 | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924083583 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9098900407 | ||||||||
FaxNumber: | 9098900575 | ||||||||
Practice Location | |||||||||
Address1: | 16455 MAIN ST | ||||||||
Address2: |   | ||||||||
City: | HESPERIA | ||||||||
State: | CA | ||||||||
PostalCode: | 923453554 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7609472161 | ||||||||
FaxNumber: | 7609473673 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/10/2006 | ||||||||
LastUpdateDate: | 11/14/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | A35300 | CA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 00A541260 | 05 | CA |   | MEDICAID | 00A353000 | 01 | CA | MEDI-CAL | OTHER |