Basic Information
| Provider Information | |||||||||
| NPI: | 1649739749 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BERRA | ||||||||
| FirstName: | MADALIN | ||||||||
| MiddleName: | ROSE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S MAIN ST STE 1200 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145097847 | ||||||||
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| Practice Location | |||||||||
| Address1: | 505 S MAIN ST STE 525 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928684553 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144565631 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/18/2019 | ||||||||
| LastUpdateDate: | 06/15/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/15/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | PTL1249 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2080P0205X | 179640 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Endocrinology |
No ID Information.