Provider Demographics
NPI:1851367528
Name:BANQUERIGO, ELDINE A (MD)
Entity Type:Individual
Prefix:
First Name:ELDINE
Middle Name:A
Last Name:BANQUERIGO
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 1:8112 MILLIKEN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7472
Mailing Address - Country:US
Mailing Address - Phone:909-466-6410
Mailing Address - Fax:909-466-5667
Practice Address - Street 1:8112 MILLIKEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7472
Practice Address - Country:US
Practice Address - Phone:909-466-6410
Practice Address - Fax:909-466-5667
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-23
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53530207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A535300Medicaid
CA33-0917177OtherFEDERAL TAX ID
CA00A535300Medicaid