Basic Information
| Provider Information | |||||||||
| NPI: | 1669490553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERON | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 80099 | ||||||||
| Address2: | |||||||||
| City: | CITY OF INDUSTRY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917168099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492638620 | ||||||||
| FaxNumber: | 9492631639 | ||||||||
| Practice Location | |||||||||
| Address1: | 79970 CEDAR CRST | ||||||||
| Address2: | |||||||||
| City: | LA QUINTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922535032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7605646383 | ||||||||
| FaxNumber: | 7605646383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 10/25/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | C27346 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 00C273460 | 01 | CA | BS | OTHER | 00C273460 | 05 | CA | MEDICAID | P00374944 | 01 | CA | RR MC | OTHER |