Healthcare Provider Details

I. General information

NPI: 1265458210
Provider Name (Legal Business Name): NEWPORT DOCTORS MEDICAL GROUP INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/14/2006
Last Update Date: 04/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

401 OLD NEWPORT BLVD STE 201
NEWPORT BEACH CA
92663-4289
US

IV. Provider business mailing address

401 OLD NEWPORT BLVD STE 201
NEWPORT BEACH CA
92663-4289
US

V. Phone/Fax

Practice location:
  • Phone: 949-999-2950
  • Fax: 949-999-2960
Mailing address:
  • Phone: 949-999-2950
  • Fax: 949-999-2960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG48231
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG39611
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG23417
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberA33589
License Number StateCA

VIII. Authorized Official

Name: DAVID A GEHRET
Title or Position: PRESIDENT
Credential: M.D.
Phone: 949-999-2977