Provider Demographics
NPI:1629330436
Name:WONOPRABOWO, JEFFREY (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:
Last Name:WONOPRABOWO
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 1:11234 ANDERSON ST
Mailing Address - Street 2:GME OFFICE CSP 21005
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2804
Mailing Address - Country:US
Mailing Address - Phone:909-558-7263
Mailing Address - Fax:909-558-0427
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:GME OFFICE CSP 21005
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:909-558-7263
Practice Address - Fax:909-558-0427
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2020-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126969207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine