Healthcare Provider Details

I. General information

NPI: 1861356636
Provider Name (Legal Business Name): NOLAN DESA MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/15/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1666 TUSTIN AVE
COSTA MESA CA
92627-3247
US

IV. Provider business mailing address

1666 TUSTIN AVE
COSTA MESA CA
92627-3247
US

V. Phone/Fax

Practice location:
  • Phone: 714-421-1718
  • Fax:
Mailing address:
  • Phone: 714-421-1718
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: NOLAN S DESA
Title or Position: PRESIDENT
Credential: MD
Phone: 714-421-1718