Healthcare Provider Details

I. General information

NPI: 1154410629
Provider Name (Legal Business Name): PAUL GENSER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: PAUL ANTHONY GENSER M.D.

II. Dates (important events)

Enumeration Date: 10/12/2006
Last Update Date: 02/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 IRVINE BLVD
TUSTIN CA
92780-3804
US

IV. Provider business mailing address

17360 BROOKHURST ST ATTN: MCMF - CREDENTIALING DEPARTMENT
FOUNTAIN VALLEY CA
92708-3720
US

V. Phone/Fax

Practice location:
  • Phone: 714-838-8878
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG32897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: