Basic Information
| Provider Information | |||||||||
| NPI: | 1144461823 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MARILOU R. SOBRERA, M.D., INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60790 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911166790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8188456206 | ||||||||
| FaxNumber: | 6263960851 | ||||||||
| Practice Location | |||||||||
| Address1: | 18300 US HIGHWAY 18 | ||||||||
| Address2: | |||||||||
| City: | APPLE VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923072206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602422311 | ||||||||
| FaxNumber: | 7602429167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2009 | ||||||||
| LastUpdateDate: | 07/23/2010 | ||||||||
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| AuthorizedOfficialLastName: | SOBRERA | ||||||||
| AuthorizedOfficialFirstName: | MARILOU | ||||||||
| AuthorizedOfficialMiddleName: | ROSALES | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7609537462 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A37096 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A370960 | 05 | CA | MEDICAID | 00A370961 | 05 | CA | MEDICAID |