Healthcare Provider Details

I. General information

NPI: 1255398533
Provider Name (Legal Business Name): UCI DEPARTMENT OF UROLOGY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2006
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 THE CITY DR S
ORANGE CA
92868
US

IV. Provider business mailing address

PO BOX 51342
LOS ANGELES CA
90051-5642
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-8500
  • Fax: 714-456-8572
Mailing address:
  • Phone: 714-456-6054
  • Fax: 888-378-5391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number
License Number State

VIII. Authorized Official

Name: UCI HEALTH PROVIDER RELATIONS
Title or Position: UPS PROVIDER RELATIONS
Credential:
Phone: 714-456-2986