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Individual

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Active
Sole proprietor
Yes

Provider details

NPI number
Gender
Man
Credential
DO

Contact information

Practice address
101 E VALENCIA MESA DR, FULLERTON, CA 92835-3809
(714) 447-5027
Mailing address
101 E VALENCIA MESA DR, FULLERTON, CA 92835-3809
(714) 992-3000

Taxonomy

Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
DO21851
OR
208M00000X
Hospitalist Physician
Primary
20A9726
CA

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
110186783
RR MEDICARE PTAN NUMBER
OR
05
134037
OR
01
1407812365
NBMC GROUP NPI NUMBER
OR
01
CD8723
RR MEDICARE GROUP NUMBER
OR
01
R0000WFBTV
MEDICARE GROUP PIN NUMBER
OR
Enumeration date
12/12/2005
Last updated
04/19/2018
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