Healthcare Provider Details

I. General information

NPI: 1689011074
Provider Name (Legal Business Name): PEJMAN RAEISI-GIGLOU DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2013
Last Update Date: 12/05/2023
Certification Date: 12/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

681 S PARKER ST STE 100
ORANGE CA
92868-4719
US

IV. Provider business mailing address

3080 BRISTOL ST STE 150
COSTA MESA CA
92626-3068
US

V. Phone/Fax

Practice location:
  • Phone: 877-430-7337
  • Fax:
Mailing address:
  • Phone: 877-430-7337
  • Fax: 714-445-0245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number20A18693
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: