Provider Demographics
NPI:1215022736
Name:SMALL, GEORGE H (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:H
Last Name:SMALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GEORGE
Other - Middle Name:H
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 10999-0999
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423
Mailing Address - Country:US
Mailing Address - Phone:909-528-3639
Mailing Address - Fax:909-783-8985
Practice Address - Street 1:1800 WESTERN AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1352
Practice Address - Country:US
Practice Address - Phone:909-885-1542
Practice Address - Fax:909-327-2756
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA34324207V00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialist
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1992460794Medicaid