Basic Information
| Provider Information | |||||||||
| NPI: | 1902909187 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NIEBERG | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | HENRY | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1449 | ||||||||
| Address2: | |||||||||
| City: | BREA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928221449 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149961633 | ||||||||
| FaxNumber: | 7149969267 | ||||||||
| Practice Location | |||||||||
| Address1: | 950 S ARROYO PKWY | ||||||||
| Address2: | FL 3 | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053932 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263040782 | ||||||||
| FaxNumber: | 6266582848 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 02/14/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | A67350 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 00A673500 | 05 | CA | MEDICAID | P00139012 | 01 | CA | RAILROAD MEDICARE PROVIDE | OTHER | 00A673500 | 01 | CA | BLUE SHIELD | OTHER | DB9540 | 01 | GA | RAILROAD RETIREMENT | OTHER |