Healthcare Provider Details

I. General information

NPI: 1174023477
Provider Name (Legal Business Name): VM PED MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 02/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10900 WARNER AVE STE 122
FOUNTAIN VALLEY CA
92708-3846
US

IV. Provider business mailing address

10900 WARNER AVE STE 122
FOUNTAIN VALLEY CA
92708-3846
US

V. Phone/Fax

Practice location:
  • Phone: 281-704-3833
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA111702
License Number StateCA

VIII. Authorized Official

Name: THAO N VO
Title or Position: AUTHORIZED OFFICIAL
Credential: MD
Phone: 281-704-3833