Healthcare Provider Details

I. General information

NPI: 1578583365
Provider Name (Legal Business Name): PHYLLIS F AGRAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2006
Last Update Date: 11/30/2021
Certification Date: 11/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

805 W LA VETA AVE SUITE 108
ORANGE CA
92868-3901
US

IV. Provider business mailing address

805 W LA VETA AVE SUITE 108
ORANGE CA
92868-3901
US

V. Phone/Fax

Practice location:
  • Phone: 714-744-0776
  • Fax: 714-744-6033
Mailing address:
  • Phone: 714-744-0776
  • Fax: 714-744-6033

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberG37725
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: