Healthcare Provider Details

I. General information

NPI: 1942499793
Provider Name (Legal Business Name): ENDOCRINOLOGY MEDICAL GROUP OF ORANGE COUNTY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 11/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W LA VETA AVE 220
ORANGE CA
92868-4403
US

IV. Provider business mailing address

725 W LA VETA AVE 220
ORANGE CA
92868-4403
US

V. Phone/Fax

Practice location:
  • Phone: 714-771-5700
  • Fax: 714-771-7797
Mailing address:
  • Phone: 714-771-5700
  • Fax: 714-771-7797

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberG25017
License Number StateCA

VIII. Authorized Official

Name: THERESA A BANKHARDT
Title or Position: ON SITE OFFICE MANAGER
Credential:
Phone: 714-771-5700