MEDICARE: SOCAL ONCOPLASTIC SURGERY PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208200000X	Plastic Surgery Physician

General Provider Information

NPI Number	:	1013733641
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SOCAL ONCOPLASTIC SURGERY PC

Provider Business Mailing Address
First Line	:	2661 VISTA ORNADA
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92660-3555
Country	:	US
Telephone Number	:	949-229-7971
Fax Number	:	949-539-0897

Provider Business Practice Location Address
First Line	:	601 DOVER DR STE 2
Second Line	:
City	:	NEWPORT BEACH
State	:	CA
Zip	:	92663-5700
Country	:	US
Telephone Number	:	949-229-7971
Fax Number	:	949-539-0897

Authorized Official
Title or Position	:	OWNER
Name	:	BROCK LANIER
Credential	:	MD
Telephone Number	:	949-229-7971

Provider Enumeration Date	:	11/27/2024
Last Update Date	:	11/27/2024

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