Healthcare Provider Details

I. General information

NPI: 1104960749
Provider Name (Legal Business Name): S M MULTISPECIALTY MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/17/2022
Certification Date: 10/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2492 WALNUT AVE SUITE 110
TUSTIN CA
92780-6953
US

IV. Provider business mailing address

2492 WALNUT AVE SUITE 110
TUSTIN CA
92780-6953
US

V. Phone/Fax

Practice location:
  • Phone: 714-669-1997
  • Fax: 714-573-7424
Mailing address:
  • Phone: 714-669-1997
  • Fax: 714-573-7424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA37744
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20A8503
License Number StateCA

VIII. Authorized Official

Name: SUNIL MAPARA
Title or Position: PRESIDENT
Credential:
Phone: 714-970-0911