Healthcare Provider Details

I. General information

NPI: 1083526883
Provider Name (Legal Business Name): IMPACT MEDICAL ASSOCIATES NORTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6327 N FRESNO ST STE 104
FRESNO CA
93710-5236
US

IV. Provider business mailing address

5355 AVENIDA ENCINAS STE 103
CARLSBAD CA
92008-4332
US

V. Phone/Fax

Practice location:
  • Phone: 714-905-9503
  • Fax:
Mailing address:
  • Phone: 714-905-9503
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MIKE CONNELLY
Title or Position: CEO
Credential:
Phone: 714-905-9503