Provider Demographics
NPI:1619948502
Name:RENTERIA, ADALBERTO (MD)
Entity Type:Individual
Prefix:
First Name:ADALBERTO
Middle Name:
Last Name:RENTERIA
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 1:2100 DOUGLAS BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95661-3804
Mailing Address - Country:US
Mailing Address - Phone:916-865-1790
Mailing Address - Fax:
Practice Address - Street 1:1524 W LACEY BLVD
Practice Address - Street 2:
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-5965
Practice Address - Country:US
Practice Address - Phone:559-537-0053
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31454207Q00000X
CAG65072207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ791914Medicaid
CA75412Medicare PIN
AZF20294Medicare UPIN