Provider Demographics
NPI:1093042970
Name:PAULUS SANTOSO MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PAULUS SANTOSO MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PAULUS
Authorized Official - Middle Name:LIEM
Authorized Official - Last Name:SANTOSO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-530-8989
Mailing Address - Street 1:6969 BROCKTON AVE
Mailing Address - Street 2:SUITE A-B
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3809
Mailing Address - Country:US
Mailing Address - Phone:951-530-8989
Mailing Address - Fax:951-530-8877
Practice Address - Street 1:6969 BROCKTON AVE
Practice Address - Street 2:SUITE A-B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3809
Practice Address - Country:US
Practice Address - Phone:951-530-8989
Practice Address - Fax:951-530-8877
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-12
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85478207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A854780Medicaid
CA00A854780OtherMEDICARE
73276Medicare UPIN