Provider Demographics
NPI:1649825803
Name:VERBONITZ, MIA C (RVT, RDMS)
Entity type:Individual
Prefix:
First Name:MIA
Middle Name:C
Last Name:VERBONITZ
Suffix:
Gender:F
Credentials:RVT, RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29450 WOODEN BOAT DR
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92585-9067
Mailing Address - Country:US
Mailing Address - Phone:760-450-2792
Mailing Address - Fax:
Practice Address - Street 1:29450 WOODEN BOAT DR
Practice Address - Street 2:
Practice Address - City:MENIFEE
Practice Address - State:CA
Practice Address - Zip Code:92585-9067
Practice Address - Country:US
Practice Address - Phone:760-450-2792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-05
Last Update Date:2019-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1042882085U0001X, 2471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Ultrasound
No2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography