Healthcare Provider Details

I. General information

NPI: 1548407455
Provider Name (Legal Business Name): SIMON MADORSKY M.D A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2009
Last Update Date: 01/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1140 W LA VETA AVE SUITE 515
ORANGE CA
92868-4223
US

IV. Provider business mailing address

PO BOX 15788
NEWPORT BEACH CA
92659-5788
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-6928
  • Fax: 714-543-8804
Mailing address:
  • Phone: 949-574-4638
  • Fax: 949-574-4680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YS0123X
TaxonomyFacial Plastic Surgery Physician
License NumberA50075
License Number StateCA

VIII. Authorized Official

Name: SIMON J MADORSKY
Title or Position: OWNER
Credential: M.D
Phone: 714-543-2000