Healthcare Provider Details

I. General information

NPI: 1942654439
Provider Name (Legal Business Name): UC IRVINE HEALTH DERMATOLOGY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 NEWPORT BLVD SUITE 240
COSTA MESA CA
92627-3786
US

IV. Provider business mailing address

PO BOX 513230
LOS ANGELES CA
90051-3230
US

V. Phone/Fax

Practice location:
  • Phone: 949-999-2413
  • Fax: 949-824-0606
Mailing address:
  • Phone: 714-456-3760
  • Fax: 714-456-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MANUEL PORTO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-456-2986