Healthcare Provider Details

I. General information

NPI: 1437887395
Provider Name (Legal Business Name): ANGELA M COLOMBO MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/09/2022
Last Update Date: 10/25/2023
Certification Date: 10/25/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20072 SW BIRCH ST STE 190
NEWPORT BEACH CA
92660-0799
US

IV. Provider business mailing address

27762 ANTONIO PKWY STE 325
LADERA RANCH CA
92694-1140
US

V. Phone/Fax

Practice location:
  • Phone: 949-354-4161
  • Fax: 833-667-0260
Mailing address:
  • Phone: 949-235-7735
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QC1800X
TaxonomyCorporate Health Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ANGELA M. COLOMBO
Title or Position: CEO
Credential: MD
Phone: 949-354-4161