Provider Demographics
NPI:1700124161
Name:KARTONO WINARDI, BERNARDUS GANI SUGIARTO (MD)
Entity Type:Individual
Prefix:
First Name:BERNARDUS
Middle Name:GANI SUGIARTO
Last Name:KARTONO WINARDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2050 S BLOSSER RD
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-7310
Mailing Address - Country:US
Mailing Address - Phone:805-361-8028
Mailing Address - Fax:805-361-8097
Practice Address - Street 1:425 W CENTRAL AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2805
Practice Address - Country:US
Practice Address - Phone:805-737-1169
Practice Address - Fax:805-737-1772
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-19
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
282N00000X
CAA135298208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No282N00000XHospitalsGeneral Acute Care Hospital