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General NPI Number Information
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NPI Number | 1912176728
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Entity Type | Organization
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Legal Business Name | GEORGE O. DETARNOWSKY, JR M.D., INC.
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Dates
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Enumeration Date | 02/26/2008
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Last Update Date | 10/21/2008
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Provider Practice Location Address
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Address Line | 355 PLACENTIA AVE SUITE 300
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-3311
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Country | US
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Telephone | 949-574-5026
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Fax | 949-548-8893
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Provider Business Mailing Address
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Address Line | 355 PLACENTIA AVE SUITE 300
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City | NEWPORT BEACH
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State | CA
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Zip | 92663-3311
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Country | US
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Telephone | 949-574-5026
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Fax | 949-548-8893
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Authorized Official
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Title or Position | OWNER
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Name | MR. GEORGE OLIVIER DETARNOWSKY JR.
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Credential | M.D.
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Telephone | 949-574-5026
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 305R00000X
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Taxonomy Name | Preferred Provider Organization
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License Number | G41113
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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License Number | G41113
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License Number State | CA
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