Basic Information
Provider Information | |||||||||
NPI: | 1700124161 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | KARTONO WINARDI | ||||||||
FirstName: | BERNARDUS | ||||||||
MiddleName: | GANI SUGIARTO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2050 S BLOSSER RD | ||||||||
Address2: |   | ||||||||
City: | SANTA MARIA | ||||||||
State: | CA | ||||||||
PostalCode: | 934587310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8053618028 | ||||||||
FaxNumber: | 8053618097 | ||||||||
Practice Location | |||||||||
Address1: | 425 W CENTRAL AVE | ||||||||
Address2: | SUITE 201 | ||||||||
City: | LOMPOC | ||||||||
State: | CA | ||||||||
PostalCode: | 934362805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8057371169 | ||||||||
FaxNumber: | 8057371772 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/19/2013 | ||||||||
LastUpdateDate: | 11/21/2016 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X |   |   | N |   | Hospitals | General Acute Care Hospital |   | 208000000X | A135298 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.