Basic Information
| Provider Information | |||||||||
| NPI: | 1699717306 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RADA | ||||||||
| FirstName: | RENATO | ||||||||
| MiddleName: | G | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 625 FAIR OAKS AVE STE 270 | ||||||||
| Address2: | |||||||||
| City: | SOUTH PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910305801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263462455 | ||||||||
| FaxNumber: | 6266393005 | ||||||||
| Practice Location | |||||||||
| Address1: | 190 E HIGHLAND AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924043658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098824968 | ||||||||
| FaxNumber: | 8778607268 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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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 | 207Q00000X | A37714 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A377140 | 05 | CA | MEDICAID | P01288545/DU4034 | 01 | CA | RAILROAD MEDICARE- SAN BERNARDINO | OTHER | 00A377140 | 01 | CA | MEDI-CAL | OTHER |