Healthcare Provider Details

I. General information

NPI: 1013180355
Provider Name (Legal Business Name): IRVING LEE GISLASON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 05/12/2021
Certification Date: 05/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12443 LEWIS ST. STE. 103
GARDEN GROVE CA
92840-4650
US

IV. Provider business mailing address

7404 E. SADDLEHILL TRL
ORANGE CA
92869-2310
US

V. Phone/Fax

Practice location:
  • Phone: 714-971-7652
  • Fax: 714-971-8927
Mailing address:
  • Phone: 714-971-7652
  • Fax: 714-971-8927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberA24010
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: