Healthcare Provider Details

I. General information

NPI: 1508556465
Provider Name (Legal Business Name): INTERVENTIONAL GASTROENTEROLOGY CONSULTANTS A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2023
Last Update Date: 05/12/2023
Certification Date: 05/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4845 VIA DEL CERRO
YORBA LINDA CA
92887-2641
US

IV. Provider business mailing address

4845 VIA DEL CERRO
YORBA LINDA CA
92887-2641
US

V. Phone/Fax

Practice location:
  • Phone: 714-305-9507
  • Fax: 888-818-3162
Mailing address:
  • Phone: 714-305-9507
  • Fax: 888-818-3162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number
License Number State

VIII. Authorized Official

Name: LIZ SHEPHERD
Title or Position: DIRECTOR OF CREDENTIALING
Credential:
Phone: 951-256-4360