Healthcare Provider Details

I. General information

NPI: 1750110672
Provider Name (Legal Business Name): IDEAL MOBILE MD MEDICAL GROUP, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9550 WARNER AVE STE 250
FOUNTAIN VALLEY CA
92708-2842
US

IV. Provider business mailing address

16027 BROOKHURST ST STE I-109
FOUNTAIN VALLEY CA
92708-1551
US

V. Phone/Fax

Practice location:
  • Phone: 657-217-4500
  • Fax: 627-217-4501
Mailing address:
  • Phone: 657-217-4500
  • Fax: 657-217-4501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. JULIE D DONG
Title or Position: SECRETARY
Credential:
Phone: 657-217-4500