Provider Demographics
NPI:1043566029
Name:EUGENE I. EMEMBOLU, M.D., INC.
Entity Type:Organization
Organization Name:EUGENE I. EMEMBOLU, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:IKEM
Authorized Official - Last Name:EMEMBOLU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-882-1711
Mailing Address - Street 1:399 E. HIGHLAND AVENUE
Mailing Address - Street 2:SUITE 506
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3865
Mailing Address - Country:US
Mailing Address - Phone:909-882-1711
Mailing Address - Fax:909-881-1431
Practice Address - Street 1:399 E. HIGHLAND AVENUE
Practice Address - Street 2:SUITE 506
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3865
Practice Address - Country:US
Practice Address - Phone:909-882-1711
Practice Address - Fax:909-881-1431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28708207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty