Healthcare Provider Details

I. General information

NPI: 1962013870
Provider Name (Legal Business Name): PHILIP RYAN M CAMILON, MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2020
Last Update Date: 08/17/2020
Certification Date: 08/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 275
ORANGE CA
92868-4547
US

IV. Provider business mailing address

505 S MAIN ST STE 275
ORANGE CA
92868-4547
US

V. Phone/Fax

Practice location:
  • Phone: 714-836-6607
  • Fax: 714-836-6600
Mailing address:
  • Phone: 714-836-6607
  • Fax: 714-836-6600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: PHILIP RYAN MOLARTE CAMILON
Title or Position: CEO
Credential: MD
Phone: 714-900-1117