=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528128360
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 5 STAR MEDICAL INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/11/2006
-----------------------------------------------------
Last Update Date | 07/23/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2230 W CHAPMAN AVE SUITE 124
-----------------------------------------------------
City | ORANGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92868-2333
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-926-6900
-----------------------------------------------------
Fax | 714-464-4467
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8251 LA PALMA AVE # 240
-----------------------------------------------------
City | BUENA PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90620-3205
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-926-6900
-----------------------------------------------------
Fax | 714-464-4467
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. DONAH BULOSAN
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 714-926-6900
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | A79396
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------