Healthcare Provider Details

I. General information

NPI: 1396929774
Provider Name (Legal Business Name): ORANGE COUNTY FOOT & ANKLE GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/21/2007
Last Update Date: 12/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17400 IRVINE BLVD SUITE J
TUSTIN CA
92780-3030
US

IV. Provider business mailing address

17400 IRVINE BLVD SUITE J
TUSTIN CA
92780-3030
US

V. Phone/Fax

Practice location:
  • Phone: 714-832-0271
  • Fax: 714-832-0272
Mailing address:
  • Phone: 714-832-0271
  • Fax: 714-832-0272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4301
License Number StateCA

VIII. Authorized Official

Name: MR. JONATHAN IAN BENNETT
Title or Position: PRESIDENT
Credential: DPM
Phone: 714-832-0271