Healthcare Provider Details

I. General information

NPI: 1639669229
Provider Name (Legal Business Name): PACIFIC OAKS MEDICAL GROUP & SUBSIDIARY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2018
Last Update Date: 07/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3140 RED HILL AVE STE 120
COSTA MESA CA
92626-3400
US

IV. Provider business mailing address

150 N ROBERTSON BLVD STE 300
BEVERLY HILLS CA
90211-2145
US

V. Phone/Fax

Practice location:
  • Phone: 949-263-1242
  • Fax:
Mailing address:
  • Phone: 310-652-2562
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: ROBERT SCOTT LOITMAN
Title or Position: CONTROLLER
Credential:
Phone: 310-652-2562