Provider Demographics
NPI:1417993890
Name:KEREGHA, PATIENCE B (MD)
Entity Type:Individual
Prefix:
First Name:PATIENCE
Middle Name:B
Last Name:KEREGHA
Suffix:
Gender:F
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:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:303-953-8260
Practice Address - Street 1:9449 SAN FERNANDO RD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352-1421
Practice Address - Country:US
Practice Address - Phone:818-767-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-22
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA51718174400000X, 207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A517180Medicaid
CA00A517180OtherBS CA
CAP00124489OtherRAILROAD MEDICARE
CA00A517180OtherBS CA
CACD571ZMedicare PIN
CA00A517180Medicaid