Provider Demographics
NPI:1689674582
Name:KOUNANG, ROBERTUS HASAN (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERTUS
Middle Name:HASAN
Last Name:KOUNANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:646 PALO ALTO DR
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-7321
Mailing Address - Country:US
Mailing Address - Phone:909-793-4585
Mailing Address - Fax:909-307-8031
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:212
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-6250
Practice Address - Fax:909-580-6369
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-21
Last Update Date:2022-12-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA40627208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A406270Medicaid
CA00A406270Medicare ID - Type Unspecified
CA00A406270Medicaid