Healthcare Provider Details

I. General information

NPI: 1902817158
Provider Name (Legal Business Name): MORTON PHILIP ISRAEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 11/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

770 MAGNOLIA AVE SUITE 1X
CORONA CA
92879-3120
US

IV. Provider business mailing address

770 MAGNOLIA AVE SUITE 1X
CORONA CA
92879-3120
US

V. Phone/Fax

Practice location:
  • Phone: 951-734-9750
  • Fax: 951-734-3404
Mailing address:
  • Phone: 951-734-9750
  • Fax: 951-734-3404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number0788400001
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG19795
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: