Provider Demographics
NPI:1710439492
Name:PEDROZA, CONRAD RODNEY
Entity Type:Individual
Prefix:
First Name:CONRAD
Middle Name:RODNEY
Last Name:PEDROZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 E 4TH ST STE 200
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3916
Mailing Address - Country:US
Mailing Address - Phone:714-824-8140
Mailing Address - Fax:714-824-8142
Practice Address - Street 1:2001 E 4TH ST STE 200
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705
Practice Address - Country:US
Practice Address - Phone:714-824-8140
Practice Address - Fax:714-824-8142
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-28
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X, 302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC5104288OtherMENTAL HEALTH