Healthcare Provider Details

I. General information

NPI: 1891860748
Provider Name (Legal Business Name): SOUTH COAST PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1720 W BALL RD STE.#1
ANAHEIM CA
92804-5500
US

IV. Provider business mailing address

1720 W BALL RD STE.#1
ANAHEIM CA
92804-5500
US

V. Phone/Fax

Practice location:
  • Phone: 714-991-5141
  • Fax: 714-991-5144
Mailing address:
  • Phone: 714-991-5141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. JACOB WOLSZTEJN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-991-5141