Provider Demographics
NPI:1902019672
Name:DOUGLAS J BESETH MD A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:DOUGLAS J BESETH MD A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BESETH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-908-5086
Mailing Address - Street 1:1277 UPLAND HILLS DR S
Mailing Address - Street 2:
Mailing Address - City:UPLAND
Mailing Address - State:CA
Mailing Address - Zip Code:91786-2439
Mailing Address - Country:US
Mailing Address - Phone:909-908-5086
Mailing Address - Fax:
Practice Address - Street 1:999 SAN BERNARDINO RD
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4920
Practice Address - Country:US
Practice Address - Phone:909-908-5086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2013-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC30121208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA34124Medicare UPIN
CAZZZ23034ZMedicare ID - Type Unspecified