Basic Information
Provider Information | |||||||||
NPI: | 1235187311 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UC REGENTS UCI DEPT OF PEDIATRICS | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | REGENT OF THE UNIVERSITY OF CALIFORNIA | ||||||||
OtherOrganizationType: | 5 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 31001-2494 | ||||||||
Address2: |   | ||||||||
City: | PASADENA | ||||||||
State: | CA | ||||||||
PostalCode: | 911102494 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 101 THE CITY DR S | ||||||||
Address2: |   | ||||||||
City: | ORANGE | ||||||||
State: | CA | ||||||||
PostalCode: | 92868 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144568068 | ||||||||
FaxNumber: | 7144563765 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2006 | ||||||||
LastUpdateDate: | 01/30/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PROVIDER RELATIONS | ||||||||
AuthorizedOfficialFirstName: | UCI HEALTH | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | UPS PROVIDER RELATIONS | ||||||||
AuthorizedOfficialTelephone: | 7144562986 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207SG0205X |   |   | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Medical Genetics | Ph.D. Medical Genetics | 208000000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | ZZZ54107Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ54113Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ54104Z | 01 | CA | BLUE SHIELD | OTHER | ZZZ54109Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ54112Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ04921Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | CG7642 | 01 | CA | RAILROAD MEDICARE GROUP | OTHER | GR0029040 | 01 | CA | MEDI-CAL GROUP # | OTHER | ZZZ17751Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ06275Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ54114Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ54103Z | 01 | CA | BLUE SHIELD GROUP # | OTHER | ZZZ54106Z | 01 | CA | BLUE SHIELD GROUP # | OTHER |