Healthcare Provider Details

I. General information

NPI: 1154365997
Provider Name (Legal Business Name): FULLERTON ORTHOPAEDIC SURGERY MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 06/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 LAGUNA RD SUITE A
FULLERTON CA
92835-3635
US

IV. Provider business mailing address

101 LAGUNA RD SUITE A
FULLERTON CA
92835-3635
US

V. Phone/Fax

Practice location:
  • Phone: 714-879-0050
  • Fax: 714-879-0229
Mailing address:
  • Phone: 714-879-0050
  • Fax: 714-879-0229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberFNP2831
License Number StateCA

VIII. Authorized Official

Name: STEWART L. SHANFIELD
Title or Position: PRESIDENT
Credential: M.D.
Phone: 714-879-0050