Basic Information
Provider Information | |||||||||
NPI: | 1366063125 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | CARECONNECTMD CA PC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 16162 BEACH BLVD STE 100 | ||||||||
Address2: |   | ||||||||
City: | HUNTINGTON BEACH | ||||||||
State: | CA | ||||||||
PostalCode: | 926473828 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887899585 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3090 BRISTOL ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | COSTA MESA | ||||||||
State: | CA | ||||||||
PostalCode: | 926263061 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8887899585 | ||||||||
FaxNumber: | 5628034500 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/04/2020 | ||||||||
LastUpdateDate: | 08/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | MLOT | ||||||||
AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 8887899585 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: | 08/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X |   |   | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |   |
No ID Information.