Provider Demographics
NPI:1558454355
Name:BRESENO, JUSTINA M (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTINA
Middle Name:M
Last Name:BRESENO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JUSTINA
Other - Middle Name:ROBLES
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:20365 SHAKARI CIRCLE
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92887
Mailing Address - Country:US
Mailing Address - Phone:951-601-6802
Mailing Address - Fax:951-604-9263
Practice Address - Street 1:6485 DAY ST
Practice Address - Street 2:SUITE 103
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-0929
Practice Address - Country:US
Practice Address - Phone:714-777-2593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA50599208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
F58808Medicare UPIN