Healthcare Provider Details

I. General information

NPI: 1669993218
Provider Name (Legal Business Name): SPORTS MEDICINE AND ORTHOPAEDIC INSTITUTE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2017
Last Update Date: 02/13/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12490 BUSINESS CENTER DR STE 100
VICTORVILLE CA
92395-5833
US

IV. Provider business mailing address

17100B BEAR VALLEY RD # 283
VICTORVILLE CA
92395-5851
US

V. Phone/Fax

Practice location:
  • Phone: 760-522-8585
  • Fax: 760-243-4276
Mailing address:
  • Phone: 760-552-8585
  • Fax: 760-243-4276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberA144350
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License NumberA144350
License Number StateCA

VIII. Authorized Official

Name: DR. SAMIR NAYYAR
Title or Position: PRESIDENT
Credential: M.D.
Phone: 760-552-8585