Basic Information
| Provider Information | |||||||||
| NPI: | 1619130655 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DEMETERCO-BERGGREN | ||||||||
| FirstName: | CARLA | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D. | ||||||||
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| OtherLastName: | DEMETERCO | ||||||||
| OtherFirstName: | CARLA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3860 CALLE FORTUNADA | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096303 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8110 BIRMINGHAM WAY | ||||||||
| Address2: | BLDG 28 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921232758 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589664032 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2008 | ||||||||
| LastUpdateDate: | 07/09/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A98629 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0205X | A98629 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
No ID Information.