Healthcare Provider Details

I. General information

NPI: 1609252824
Provider Name (Legal Business Name): UC IRVINE HEALTH MEDICAL GROUP- TUSTIN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1451 IRVINE BLVD
TUSTIN CA
92780-3804
US

IV. Provider business mailing address

PO BOX 54538
LOS ANGELES CA
90054-0538
US

V. Phone/Fax

Practice location:
  • Phone: 714-456-2911
  • Fax: 855-853-4613
Mailing address:
  • Phone: 714-456-6431
  • Fax: 714-456-7754

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. MANUEL PORTO
Title or Position: PRESIDENT & CEO
Credential: M.D.
Phone: 714-456-2986