Provider Demographics
NPI:1346541380
Name:IMBERTSON, ERICK JORDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERICK
Middle Name:JORDAN
Last Name:IMBERTSON
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 1:11130 ANDERSON ST
Mailing Address - Street 2:DEPARTMENT OF GASTROENTEROLOGY
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92350-1729
Mailing Address - Country:US
Mailing Address - Phone:909-558-4811
Mailing Address - Fax:909-558-0490
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-08
Last Update Date:2018-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL33165208600000X
CAA125264207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No208600000XAllopathic & Osteopathic PhysiciansSurgery