Provider Demographics
NPI:1154329373
Name:SANTOSO, PAULUS L (MD)
Entity Type:Individual
Prefix:DR
First Name:PAULUS
Middle Name:L
Last Name:SANTOSO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6969 BROCKTON AVE
Mailing Address - Street 2:STE. 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:STE. 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
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2016-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85478207V00000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A854780Medicaid
CA00A854780Medicaid
CA00A854780Medicare ID - Type Unspecified