Provider Demographics
NPI:1891779997
Name:SIMENTAL, MAIRA E (MD)
Entity Type:Individual
Prefix:
First Name:MAIRA
Middle Name:E
Last Name:SIMENTAL
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:PO BOX 512185
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-0185
Mailing Address - Country:US
Mailing Address - Phone:626-775-3514
Mailing Address - Fax:
Practice Address - Street 1:401 E HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-3803
Practice Address - Country:US
Practice Address - Phone:909-475-2700
Practice Address - Fax:909-475-2738
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA673122085R0001X, 2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP00296252OtherRR MEDICARE ST. BERNADINE
CA00A673120Medicaid
CAA67312OtherMEDICAL LICENSE
CAWA67312GMedicare PIN
CACB229865Medicare PIN
CAH72418Medicare UPIN
CA00A673122Medicare PIN
CAWA67312CMedicare PIN
CAWA67312IMedicare PIN
CAP00296252OtherRR MEDICARE ST. BERNADINE
CAWA67312AMedicare PIN
CA00A673120Medicaid
CAWA67312BMedicare PIN
CAWA67312EMedicare PIN
CA00A673123Medicare PIN