Healthcare Provider Details

I. General information

NPI: 1023692100
Provider Name (Legal Business Name): CONNIE OH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2021
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 CORPORATE PLAZA DR
NEWPORT BEACH CA
92660-7985
US

IV. Provider business mailing address

22 CORPORATE PLAZA DR
NEWPORT BEACH CA
92660-7985
US

V. Phone/Fax

Practice location:
  • Phone: 949-722-7038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RS0010X
TaxonomySports Medicine (Internal Medicine) Physician
License NumberA181638
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: