Provider Demographics
NPI:1851305718
Name:SOBRERA, MARILOU ROSALES (MD)
Entity Type:Individual
Prefix:
First Name:MARILOU
Middle Name:ROSALES
Last Name:SOBRERA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18145 US HIGHWAY 18, SUITE A
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2210
Mailing Address - Country:US
Mailing Address - Phone:760-515-6260
Mailing Address - Fax:760-515-6260
Practice Address - Street 1:18300 US HIGHWAY18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2206
Practice Address - Country:US
Practice Address - Phone:760-242-2311
Practice Address - Fax:760-242-9167
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2012-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37096207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A379061Medicaid
CA00A379061OtherBLUE SHIELD
CABW181XMedicare PIN
A28290Medicare UPIN
CA00A379061OtherBLUE SHIELD
CABW181ZMedicare PIN
CA00A379061Medicaid