Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | DC17147 | CA |
NPI | 1023232733 |
---|---|
Provider Name | Dr. Richard C. Gerardo |
First Address | Burbank, CA 91505-2309 |
Second Address | Burbank, CA 91505-2309 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2007 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
DC 17147 | CALIFORNIA LICENSE NUMBER (01) | CA |
DC0171470 | BLUE SHIELD (01) | CA |