=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780659557
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMOND J IMATANI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/22/2006
-----------------------------------------------------
Last Update Date | 10/24/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 21 CALLE VISTA DEL SOL
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-243-6537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 21 CALLE VISTA DEL SOL
-----------------------------------------------------
City | SAN CLEMENTE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92673-6913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-243-6537
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | G26483
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------