Organization
COLLEGE MEDICAL GROUP, INC.
Active
Organization
COLLEGE MEDICAL GROUP, INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SOMSONG WATTANASAKUL TONGBAI M.D. (PRESIDENT)
(714) 564-9323
Entity
Organization
Contact information
Practice address
611 S MAIN ST, SUITE A, SANTA ANA, CA 92701-5715
(714) 564-9323
(714) 973-8885
Mailing address
611 S MAIN ST, SUITE A, SANTA ANA, CA 92701-5715
(714) 564-9323
(714) 973-8885
Taxonomy
Speciality
Code
Description
License number
State
261Q00000X
Clinic/Center
Primary
A31437
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
00A314370-151
CALOPTIMA PROVIDER NUMBER
CA
01
—
GR0011541
CHDP PROVIDER NUMBER
CA
Enumeration date
01/12/2007
Last updated
08/22/2020
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