Healthcare Provider Details

I. General information

NPI: 1801366083
Provider Name (Legal Business Name): THE DEPARTMENT OF PSYCHIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/29/2018
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20350 SW BIRCH ST
NEWPORT BEACH CA
92660-1713
US

IV. Provider business mailing address

PO BOX 31001-2473
PASADENA CA
91110-2473
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-2230
  • Fax: 949-250-9177
Mailing address:
  • Phone: 714-456-3760
  • Fax: 714-456-2398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number
License Number State

VIII. Authorized Official

Name: JUAN A MENDOZA
Title or Position: DELEGATED OFFICIAL
Credential:
Phone: 714-456-2986