Healthcare Provider Details

I. General information

NPI: 1164650206
Provider Name (Legal Business Name): TINA JUSSAL DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TINA MALIK DPM

II. Dates (important events)

Enumeration Date: 06/28/2009
Last Update Date: 06/27/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1038 E CHAPMAN AVE
ORANGE CA
92866-2111
US

IV. Provider business mailing address

1038 E CHAPMAN AVE
ORANGE CA
92866-2111
US

V. Phone/Fax

Practice location:
  • Phone: 914-771-4191
  • Fax: 714-771-2731
Mailing address:
  • Phone: 714-771-4191
  • Fax: 714-771-2731

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: