Provider Demographics
NPI:1073713962
Name:KINTANAR, AGNES B (MD)
Entity Type:Individual
Prefix:
First Name:AGNES
Middle Name:B
Last Name:KINTANAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1292 W MILL ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92410-2500
Mailing Address - Country:US
Mailing Address - Phone:909-383-9440
Mailing Address - Fax:909-383-9443
Practice Address - Street 1:1292 W MILL ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92410-2500
Practice Address - Country:US
Practice Address - Phone:909-383-9440
Practice Address - Fax:909-383-9443
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA38376208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A383761Medicaid
CA00A383760Medicaid
CACA124122Medicare PIN
CA00A383761Medicaid