Basic Information
Provider Information | |||||||||
NPI: | 1295711224 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JOSEPH MEDICAL GROUP INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6261 STANTON AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906212436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7147394325 | ||||||||
FaxNumber: | 7147394076 | ||||||||
Practice Location | |||||||||
Address1: | 6261 STANTON AVE | ||||||||
Address2: |   | ||||||||
City: | BUENA PARK | ||||||||
State: | CA | ||||||||
PostalCode: | 906212436 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7147394325 | ||||||||
FaxNumber: | 7147394076 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/21/2005 | ||||||||
LastUpdateDate: | 04/18/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CHUN | ||||||||
AuthorizedOfficialFirstName: | JOSEPH | ||||||||
AuthorizedOfficialMiddleName: | D. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT/DIRECTOR | ||||||||
AuthorizedOfficialTelephone: | 7147394325 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A80586 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207Q00000X | A82873 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   | 207R00000X | G61950 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 208000000X | G61950 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   | 111N00000X |   | CA | N | 193200000X MULTI-SPECIALTY GROUP | Chiropractic Providers | Chiropractor |   | 207K00000X | G61950 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Allergy & Immunology |   |
ID Information
ID | Type | State | Issuer | Description | 00G619500K91 | 01 | CA | CALOPT | OTHER | GR0088840 | 05 | CA |   | MEDICAID |