Healthcare Provider Details

I. General information

NPI: 1508138256
Provider Name (Legal Business Name): ORANGE COAST ANESTHESIA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2601 E CHAPMAN AVE
ORANGE CA
92869-3206
US

IV. Provider business mailing address

PO BOX 89 4940
LOS ANGELES CA
90189-4940
US

V. Phone/Fax

Practice location:
  • Phone: 714-633-0011
  • Fax:
Mailing address:
  • Phone: 516-945-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberA101740
License Number StateCA

VIII. Authorized Official

Name: DR. WYNNSON W TOM
Title or Position: PRESIDENT
Credential: M.D.
Phone: 626-204-6747