Provider Demographics
NPI:1568507259
Name:LABASAN, GERARDO PONCE (MD)
Entity Type:Individual
Prefix:
First Name:GERARDO
Middle Name:PONCE
Last Name:LABASAN
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 1:6969 BROCKTON AVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3833
Mailing Address - Country:US
Mailing Address - Phone:951-686-3575
Mailing Address - Fax:951-781-2194
Practice Address - Street 1:6969 BROCKTON AVE
Practice Address - Street 2:SUITE B
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-3833
Practice Address - Country:US
Practice Address - Phone:951-686-3575
Practice Address - Fax:951-781-2194
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86436207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A864360Medicaid
CA00LA864360Medicare ID - Type Unspecified
CAI20032Medicare UPIN