Healthcare Provider Details

I. General information

NPI: 1912556721
Provider Name (Legal Business Name): AMISTAD MULTI SPECIALTY MEDICAL GROUP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2019
Last Update Date: 09/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 S BROADWAY
SANTA ANA CA
92701-5633
US

IV. Provider business mailing address

201 S BROADWAY
SANTA ANA CA
92701-5633
US

V. Phone/Fax

Practice location:
  • Phone: 714-571-4941
  • Fax: 714-571-4941
Mailing address:
  • Phone: 714-571-4941
  • Fax: 714-571-4941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. AJAY G MEKA
Title or Position: PRESIDENT & CEO
Credential: MD
Phone: 714-571-4941