Provider Demographics
NPI:1477630580
Name:DE ANZA OBSTETRICS AND GYNECOLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:DE ANZA OBSTETRICS AND GYNECOLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GUILLERMO
Authorized Official - Middle Name:
Authorized Official - Last Name:VALENZUELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-580-3470
Mailing Address - Street 1:PO BOX 1762
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-0857
Mailing Address - Country:US
Mailing Address - Phone:951-683-2106
Mailing Address - Fax:951-638-2105
Practice Address - Street 1:4190 CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-5348
Practice Address - Country:US
Practice Address - Phone:951-683-2106
Practice Address - Fax:951-683-2105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2014-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA38671207V00000X
207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Multi-Specialty
No207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal MedicineGroup - Multi-Specialty