Organization
EAR NOSE THROAT MD INC.
Active
Organization subpart
No
Provider details
NPI number
Authorized official
JENNY BRAGANZA (CREDENTIALING MANAGER)
(562) 341-4786
Entity
Organization
Contact information
Practice address
2552 WALNUT AVE STE 130, TUSTIN, CA 92780-6970
(714) 847-9677
Mailing address
2552 WALNUT AVE STE 130, TUSTIN, CA 92780-6970
(714) 847-9677
Taxonomy
Speciality
Code
Description
License number
State
207Y00000X
Otolaryngology Physician
Primary
—
—
261Q00000X
Clinic/Center
—
—
Other
Enumeration date
04/19/2019
Last updated
04/19/2019
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