Provider Demographics
NPI:1508889585
Name:MADRID, ROBERTO (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTO
Middle Name:
Last Name:MADRID
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 1:1217 W WHITTIER BLVD
Mailing Address - Street 2:
Mailing Address - City:MONTEBELLO
Mailing Address - State:CA
Mailing Address - Zip Code:90640-4642
Mailing Address - Country:US
Mailing Address - Phone:323-728-6070
Mailing Address - Fax:323-728-2912
Practice Address - Street 1:1217 W WHITTIER BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4642
Practice Address - Country:US
Practice Address - Phone:323-728-6070
Practice Address - Fax:323-728-2912
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA56264207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGROO84064OtherPRACTICE LOCATION PAS
CAGR0084062OtherPRACTICE LOCATION MTB
CAA56264OtherMEDICAL LICENSE
CAGR0084061OtherPRACTICE LOCATION- ELA
CAGR0084061OtherPRACTICE LOCATION- ELA
CAG67544Medicare UPIN
CAWA56264D,E,CMedicare ID - Type UnspecifiedPROVIDER # 3 LOCATIONS