Provider Demographics
NPI:1801991450
Name:COLTON VALLEY MEDICAL GROUP
Entity type:Organization
Organization Name:COLTON VALLEY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:WAGIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:SUN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-825-3202
Mailing Address - Street 1:502 W VALLEY BLVD
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324
Mailing Address - Country:US
Mailing Address - Phone:909-825-3202
Mailing Address - Fax:909-825-9375
Practice Address - Street 1:502 W VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324
Practice Address - Country:US
Practice Address - Phone:909-825-3202
Practice Address - Fax:909-825-9375
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23744208D00000X
261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Not Answered261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0041960Medicaid
CA00A237440Medicaid
CA00A237440Medicaid
CAZZZ16716ZMedicare ID - Type Unspecified
CAGR0041960Medicaid