Healthcare Provider Details

I. General information

NPI: 1053576876
Provider Name (Legal Business Name): TUSTIN IRVINE MEDICAL GROUP, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25124 SPRINGFIELD CT SUITE 200
VALENCIA CA
91355-1085
US

IV. Provider business mailing address

25124 SPRINGFIELD CT SUITE 200
VALENCIA CA
91355-1085
US

V. Phone/Fax

Practice location:
  • Phone: 661-678-2600
  • Fax: 661-678-2700
Mailing address:
  • Phone: 661-678-2600
  • Fax: 661-678-2700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. JOSEPH T MALLAS
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 661-678-2626