Basic Information
Provider Information | |||||||||
NPI: | 1275909475 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | UC IRVINE HEALTH - DEPT. OF DERMATOLOGY | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 513230 | ||||||||
Address2: |   | ||||||||
City: | LOS ANGELES | ||||||||
State: | CA | ||||||||
PostalCode: | 900513230 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144563760 | ||||||||
FaxNumber: | 7144566216 | ||||||||
Practice Location | |||||||||
Address1: | 1451 IRVINE BLVD | ||||||||
Address2: |   | ||||||||
City: | TUSTIN | ||||||||
State: | CA | ||||||||
PostalCode: | 927803804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7144565902 | ||||||||
FaxNumber: | 7144565112 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2015 | ||||||||
LastUpdateDate: | 08/13/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | PORTO | ||||||||
AuthorizedOfficialFirstName: | MANUEL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
AuthorizedOfficialTelephone: | 7144562986 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | M.D. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.