Healthcare Provider Details

I. General information

NPI: 1679793376
Provider Name (Legal Business Name): ISMAEL MENA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7499 CERRITOS AVE
STANTON CA
90680-2008
US

IV. Provider business mailing address

7499 CERRITOS AVE
STANTON CA
90680-2008
US

V. Phone/Fax

Practice location:
  • Phone: 714-827-5180
  • Fax: 714-827-9993
Mailing address:
  • Phone: 714-827-5180
  • Fax: 714-827-9993

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A8152
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: