Healthcare Provider Details

I. General information

NPI: 1912176728
Provider Name (Legal Business Name): GEORGE O. DETARNOWSKY, JR M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 10/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 PLACENTIA AVE SUITE 300
NEWPORT BEACH CA
92663-3311
US

IV. Provider business mailing address

355 PLACENTIA AVE SUITE 300
NEWPORT BEACH CA
92663-3311
US

V. Phone/Fax

Practice location:
  • Phone: 949-574-5026
  • Fax: 949-548-8893
Mailing address:
  • Phone: 949-574-5026
  • Fax: 949-548-8893

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberG41113
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License NumberG41113
License Number StateCA

VIII. Authorized Official

Name: MR. GEORGE OLIVIER DETARNOWSKY JR.
Title or Position: OWNER
Credential: M.D.
Phone: 949-574-5026