Healthcare Provider Details

I. General information

NPI: 1922015072
Provider Name (Legal Business Name): HARBOR PEDIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2006
Last Update Date: 01/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 DOVER DR STE 7
NEWPORT BEACH CA
92663-5721
US

IV. Provider business mailing address

601 DOVER DR STE 7
NEWPORT BEACH CA
92663-5721
US

V. Phone/Fax

Practice location:
  • Phone: 949-465-4670
  • Fax: 949-722-6866
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateCA

VIII. Authorized Official

Name: DAVID ANTHONY MICHELIS
Title or Position: OWNER
Credential: MD
Phone: 949-645-4670