Healthcare Provider Details

I. General information

NPI: 1265591994
Provider Name (Legal Business Name): GEORGE L. MAYO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16543 BROOKHURST ST.
FOUNTAIN VALLEY CA
92708
US

IV. Provider business mailing address

16543 BROOKHURST ST.
FOUNTAIN VALLEY CA
92708
US

V. Phone/Fax

Practice location:
  • Phone: 714-531-6296
  • Fax: 714-531-6236
Mailing address:
  • Phone: 714-531-6296
  • Fax: 714-531-6236

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberG83501
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: