Healthcare Provider Details

I. General information

NPI: 1366590762
Provider Name (Legal Business Name): REGENTS OF THE UNIVERSITY OF
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 11/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868
US

IV. Provider business mailing address

PO BOX 31001-2479
PASADENA CA
91110-2479
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-8068
  • Fax: 714-456-3765
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. UCI HEALTH PROVIDER RELATIONS
Title or Position: UPS PROVIDER RELATIONS
Credential:
Phone: 714-456-2986