Basic Information
| Provider Information | |||||||||
| NPI: | 1346258688 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | JOHN O DIMOWO MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5 HOLLAND STE 101 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182568 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495882190 | ||||||||
| FaxNumber: | 9495882199 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 W LA PALMA AVE | ||||||||
| Address2: | |||||||||
| City: | ANAHEIM | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928012804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7147741450 | ||||||||
| FaxNumber: | 7149993907 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2006 | ||||||||
| LastUpdateDate: | 03/06/2008 | ||||||||
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| AuthorizedOfficialLastName: | DIMOWO | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | ORUYOPITA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9495882190 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00A525010 | 05 | CA | MEDICAID | 00A525010 | 01 | CA | BLUE SHIELD | OTHER |