MEDICARE: OPTIMAL PHYSICIAN SURGICAL GROUP

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	207XX0005X	Sports Medicine (Orthopaedic Surgery) Physician	A116169	CA

General Provider Information

NPI Number	:	1073026696
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OPTIMAL PHYSICIAN SURGICAL GROUP

Provider Business Mailing Address
First Line	:	25067 JIM BRIDGER RD
Second Line	:
City	:	HIDDEN HILLS
State	:	CA
Zip	:	91302-1128
Country	:	US
Telephone Number	:	678-596-1344
Fax Number	:	310-453-2535

Provider Business Practice Location Address
First Line	:	25067 JIM BRIDGER RD
Second Line	:
City	:	HIDDEN HILLS
State	:	CA
Zip	:	91302-1128
Country	:	US
Telephone Number	:	678-596-1344
Fax Number	:	310-453-2535

Authorized Official
Title or Position	:	CEO
Name	:	NEILESH CHODADRA
Credential	:	M.D.
Telephone Number	:	678-596-1344

Provider Enumeration Date	:	11/06/2017
Last Update Date	:	11/06/2017

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