Healthcare Provider Details

I. General information

NPI: 1336335322
Provider Name (Legal Business Name): ARMAND WIDJAJA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2007
Last Update Date: 03/03/2020
Certification Date: 03/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 E YALE LOOP STE 200
IRVINE CA
92604-4697
US

IV. Provider business mailing address

17360 BROOKHURST ST ATTN: NETWORK MANAGEMENT
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 949-551-1090
  • Fax: 949-262-5500
Mailing address:
  • Phone: 714-549-1300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA98710
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: