Healthcare Provider Details

I. General information

NPI: 1194908293
Provider Name (Legal Business Name): PEDIATRIC SURGICAL SPECIALISTS OF ORANGE COUNTY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2007
Last Update Date: 12/12/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W LA VETA AVE SUITE 100
ORANGE CA
92868-4231
US

IV. Provider business mailing address

1120 W LA VETA AVE SUITE 100
ORANGE CA
92868-4231
US

V. Phone/Fax

Practice location:
  • Phone: 714-361-4480
  • Fax: 714-361-4490
Mailing address:
  • Phone: 714-361-4480
  • Fax: 714-361-4490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberG79479
License Number StateCA

VIII. Authorized Official

Name: MISS CHRISTINA M BARRETTA
Title or Position: PRACTICE MANAGER
Credential:
Phone: 714-361-4480