Healthcare Provider Details

I. General information

NPI: 1154765709
Provider Name (Legal Business Name): NEWPORT CHILDREN MEDICAL GROUP AT MISSION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2013
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26800 CROWN VALLEY PKWY SUITE 510
MISSION VIEJO CA
92691-6384
US

IV. Provider business mailing address

26800 CROWN VALLEY PKWY SUITE 510
MISSION VIEJO CA
92691-6384
US

V. Phone/Fax

Practice location:
  • Phone: 949-364-8700
  • Fax: 949-365-1011
Mailing address:
  • Phone: 949-364-8700
  • Fax: 949-365-1011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA109148
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License NumberA47947
License Number StateCA

VIII. Authorized Official

Name: JOHANNA RODRIGUEZ-TOLEDO
Title or Position: SECRETARY
Credential: M. D.
Phone: 949-364-8700