MEDICARE: HUNTINGTON BEACH SURGERY

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	2086S0129X	Vascular Surgery Physician	A40737	CA

General Provider Information

NPI Number	:	1316012339
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUNTINGTON BEACH SURGERY

Provider Business Mailing Address
First Line	:	12828 BAYWIND PT
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-2796
Country	:	US
Telephone Number	:	714-376-9236
Fax Number	:

Provider Business Practice Location Address
First Line	:	12828 BAYWIND PT
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92130-2796
Country	:	US
Telephone Number	:	714-376-9236
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. DONEL ELSHIRE III
Credential	:	MD
Telephone Number	:	714-376-9236

Provider Enumeration Date	:	11/22/2006
Last Update Date	:	08/22/2020

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