Healthcare Provider Details

I. General information

NPI: 1336650068
Provider Name (Legal Business Name): NEWPORT PERSONAL MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2017
Last Update Date: 01/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 ODYSSEY STE 110
IRVINE CA
92618-3186
US

IV. Provider business mailing address

P.O. BOX 11807
NEWPORT BEACH CA
92658
US

V. Phone/Fax

Practice location:
  • Phone: 949-500-5662
  • Fax: 949-706-9440
Mailing address:
  • Phone: 949-500-5662
  • Fax: 949-706-9440

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT STEPHEN JENNINGS
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-500-5662