Provider Demographics
NPI:1669490553
Name:BERON, EDWARD A (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:A
Last Name:BERON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 80099
Mailing Address - Street 2:
Mailing Address - City:CITY OF INDUSTRY
Mailing Address - State:CA
Mailing Address - Zip Code:91716-8099
Mailing Address - Country:US
Mailing Address - Phone:949-263-8620
Mailing Address - Fax:949-263-1639
Practice Address - Street 1:79970 CEDAR CRST
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253-5032
Practice Address - Country:US
Practice Address - Phone:760-564-6383
Practice Address - Fax:760-564-6383
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2007-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC273462085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C273460OtherBS
CA00C273460Medicaid
CAP00374944OtherRR MC
CAA33348Medicare UPIN
CAP00374944OtherRR MC