Provider Demographics
NPI:1164500559
Name:GENEROSO S NERY M D INC
Entity Type:Organization
Organization Name:GENEROSO S NERY M D INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GENEROSO
Authorized Official - Middle Name:SANTOS
Authorized Official - Last Name:NERY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-931-1368
Mailing Address - Street 1:1183 E FOOTHILL BLVD
Mailing Address - Street 2:SUITE 135
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-4079
Mailing Address - Country:US
Mailing Address - Phone:909-931-1368
Mailing Address - Fax:909-931-1372
Practice Address - Street 1:1183 E FOOTHILL BLVD
Practice Address - Street 2:SUITE 135
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4079
Practice Address - Country:US
Practice Address - Phone:909-931-1368
Practice Address - Fax:909-931-1372
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA31007207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A310070Medicaid
CAZZZ31816ZMedicare ID - Type UnspecifiedPROVIDER ID