Healthcare Provider Details

I. General information

NPI: 1346240637
Provider Name (Legal Business Name): ELLIOT M SACKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 01/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27700 MEDICAL CENTER RD
MISSION VIEJO CA
92691-6426
US

IV. Provider business mailing address

DEPT LA 21789
PASADENA CA
91185-1789
US

V. Phone/Fax

Practice location:
  • Phone: 949-263-8620
  • Fax: 800-409-7005
Mailing address:
  • Phone: 949-263-8620
  • Fax: 800-409-7005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD00028454
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberG32657
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD00028454
License Number StateWA
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberG32657
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: