| Doctor Name: | DR. JEFFREY WONOPRABOWO |
| NPI Number: | 1629330436 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | M.D. |
| License Number: | A126969 |
| Business Practice Address: | 11234 Anderson St Gme Office Csp 21005 Loma Linda, CA - 923542804 |
| Business Phone Number: | 9095587263 |
| Business Fax Number: | 9095580427 |
| Mailing Address: | 11234 Anderson St, Gme Office Csp 21005 LOMA LINDA |
| State: | CA |
| Postal Code: | 923542804 |
| Phone Number: | 9095587263 |
| Fax Number: | 9095580427 |
| NPI Enumeration Date: | 06/08/2012 |
| NPI Last Update Date: | 12/16/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | A126969 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |