Healthcare Provider Details

I. General information

NPI: 1598201253
Provider Name (Legal Business Name): GOTTSCHALK MEDICAL PLAZA - DERMATOLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2017
Last Update Date: 01/18/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL PLAZA DR BLDG. 820
IRVINE CA
92697-3950
US

IV. Provider business mailing address

PO BOX 513230
LOS ANGELES CA
90051-3230
US

V. Phone/Fax

Practice location:
  • Phone: 949-824-0606
  • Fax: 855-209-8413
Mailing address:
  • Phone: 714-456-3760
  • Fax: 714-456-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MANUEL PORTO
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 714-456-2986