Healthcare Provider Details

I. General information

NPI: 1205105822
Provider Name (Legal Business Name): JON M. GRAZER MD MPH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/28/2011
Last Update Date: 12/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 NEWPORT CENTER DR 302
NEWPORT BEACH CA
92660-7601
US

IV. Provider business mailing address

400 NEWPORT CENTER DR
NEWPORT BEACH CA
92660-7601
US

V. Phone/Fax

Practice location:
  • Phone: 949-644-1240
  • Fax: 949-644-9274
Mailing address:
  • Phone: 949-644-1240
  • Fax: 949-644-9274

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License NumberA55421
License Number StateCA

VIII. Authorized Official

Name: DR. JON M GRAZER
Title or Position: OWNER
Credential: MD
Phone: 949-644-1240