=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639669229
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PACIFIC OAKS MEDICAL GROUP & SUBSIDIARY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/18/2018
-----------------------------------------------------
Last Update Date | 07/08/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3140 RED HILL AVE STE 120
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92626-3400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 949-263-1242
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 150 N ROBERTSON BLVD STE 300
-----------------------------------------------------
City | BEVERLY HILLS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90211-2145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-652-2562
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CONTROLLER
-----------------------------------------------------
Name | ROBERT SCOTT LOITMAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 310-652-2562
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------