Basic Information
| Provider Information | |||||||||
| NPI: | 1366753923 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TUSTIN IRVINE MEDICAL GROUP, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2980 N BEVERLY GLEN CIR | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900771726 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104749809 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15751 ROCKFIELD BLVD | ||||||||
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| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926182832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492069100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2010 | ||||||||
| LastUpdateDate: | 03/01/2011 | ||||||||
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| AuthorizedOfficialLastName: | ALEVIZOS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9492069100 | ||||||||
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| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | TUSTIN IRVINE MEDICAL GROUP, INC | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.