Healthcare Provider Details

I. General information

NPI: 1790550895
Provider Name (Legal Business Name): SENIOR DOC AZ MEDICAL PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2023
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2592 N SANTIAGO BLVD
ORANGE CA
92867-1862
US

IV. Provider business mailing address

2592 N SANTIAGO BLVD
ORANGE CA
92867-1862
US

V. Phone/Fax

Practice location:
  • Phone: 855-434-7763
  • Fax: 949-281-5550
Mailing address:
  • Phone: 855-434-7763
  • Fax: 949-281-5550

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN M GEISS
Title or Position: CEO
Credential: DO
Phone: 855-434-7763