Healthcare Provider Details

I. General information

NPI: 1457872244
Provider Name (Legal Business Name): JEEVAN SINGH SALL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2017
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27372 ALISO CREEK RD STE 200
ALISO VIEJO CA
92656-5339
US

IV. Provider business mailing address

27372 ALISO CREEK RD STE 200
ALISO VIEJO CA
92656-5339
US

V. Phone/Fax

Practice location:
  • Phone: 949-520-1012
  • Fax:
Mailing address:
  • Phone: 949-520-1012
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA164306
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberA164306
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: