Healthcare Provider Details

I. General information

NPI: 1649929472
Provider Name (Legal Business Name): MITHYA JAYAKUMAR MORTON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2022
Last Update Date: 09/28/2023
Certification Date: 09/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S MAIN ST STE 525
ORANGE CA
92868-4553
US

IV. Provider business mailing address

845 N KATHLEEN LN APT A
ORANGE CA
92867-7483
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5631
  • Fax:
Mailing address:
  • Phone: 408-223-5199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number190814
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: