Provider Demographics
NPI:1902909187
Name:NIEBERG, PAUL HENRY (MD)
Entity Type:Individual
Prefix:MR
First Name:PAUL
Middle Name:HENRY
Last Name:NIEBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1449
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92822-1449
Mailing Address - Country:US
Mailing Address - Phone:714-996-1633
Mailing Address - Fax:714-996-9267
Practice Address - Street 1:960 E GREEN ST STE 105
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91106-2443
Practice Address - Country:US
Practice Address - Phone:626-304-0782
Practice Address - Fax:626-310-0552
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2023-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA67350207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GADB9540OtherRAILROAD RETIREMENT
CA00A673500Medicaid
CAP00139012OtherRAILROAD MEDICARE PROVIDE
CA00A673500OtherBLUE SHIELD
CAWA67350AMedicare PIN
CA00A673500OtherBLUE SHIELD