Basic Information
Provider Information | |||||||||
NPI: | 1851305718 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SOBRERA | ||||||||
FirstName: | MARILOU | ||||||||
MiddleName: | ROSALES | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 18145 US HIGHWAY 18, SUITE A | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923072210 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7605156260 | ||||||||
FaxNumber: | 7605156260 | ||||||||
Practice Location | |||||||||
Address1: | 18300 US HIGHWAY18 | ||||||||
Address2: |   | ||||||||
City: | APPLE VALLEY | ||||||||
State: | CA | ||||||||
PostalCode: | 923072206 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602422311 | ||||||||
FaxNumber: | 7602429167 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/28/2006 | ||||||||
LastUpdateDate: | 10/12/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A37096 | CA | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology |   |
ID Information
ID | Type | State | Issuer | Description | 00A379061 | 05 | CA |   | MEDICAID | 00A379061 | 01 | CA | BLUE SHIELD | OTHER |