Healthcare Provider Details

I. General information

NPI: 1285207852
Provider Name (Legal Business Name): OTOOLE SURGICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2021
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

542 S FAIR OAKS AVE FL 1
PASADENA CA
91105-2606
US

IV. Provider business mailing address

PO BOX 3129
TORRANCE CA
90510-3129
US

V. Phone/Fax

Practice location:
  • Phone: 310-792-3914
  • Fax: 855-898-4055
Mailing address:
  • Phone: 310-792-3914
  • Fax: 855-898-4055

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number
License Number State

VIII. Authorized Official

Name: MARTIN ANDREW O'TOOLE
Title or Position: SECRETARY
Credential: MD
Phone: 310-792-3914