Healthcare Provider Details

I. General information

NPI: 1952578262
Provider Name (Legal Business Name): NII-KABU KABUTEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/15/2008
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 CITY BLVD W SUITE 1600
ORANGE CA
92868-2903
US

IV. Provider business mailing address

333 CITY BLVD W SUITE 1600
ORANGE CA
92868-2903
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-5453
  • Fax: 714-456-6070
Mailing address:
  • Phone: 714-456-5453
  • Fax: 714-456-6070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberA124702
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberA124702
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: