Provider Demographics
NPI:1306194261
Name:SOEPRONO MEDICAL CORPORATION
Entity Type:Organization
Organization Name:SOEPRONO MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:F
Authorized Official - Last Name:SOEPRONO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-203-5000
Mailing Address - Street 1:PO BOX 1180
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1180
Mailing Address - Country:US
Mailing Address - Phone:909-792-8600
Mailing Address - Fax:909-792-8660
Practice Address - Street 1:255 TERRACINA BLVD
Practice Address - Street 2:STE 206
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-4870
Practice Address - Country:US
Practice Address - Phone:909-792-8600
Practice Address - Fax:909-792-8660
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-27
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28216207ND0900X
CA005D0573825291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
No291U00000XLaboratoriesClinical Medical LaboratoryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
A43652Medicare UPIN