Healthcare Provider Details

I. General information

NPI: 1053488676
Provider Name (Legal Business Name): DOMENIC SIGNORELLI D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 07/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 E 17TH ST SUITE E101
SANTA ANA CA
92701-2201
US

IV. Provider business mailing address

7108 KATELLA AVE 400
STANTON CA
90680-2803
US

V. Phone/Fax

Practice location:
  • Phone: 714-543-3500
  • Fax: 866-379-7438
Mailing address:
  • Phone: 714-543-3500
  • Fax: 866-379-7238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberE4065
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XX0004X
TaxonomyOrthopaedic Foot and Ankle Surgery Physician
License NumberE 4065
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: