Basic Information
| Provider Information | |||||||||
| NPI: | 1598203242 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC IRVINE MEDICAL CENTER - INTERNAL MEDICINE WEIGHT MGMT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 31001-2482 | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911102482 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144563856 | ||||||||
| FaxNumber: | 7144568101 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 THE CITY DR S | ||||||||
| Address2: | PAVILION III | ||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144567002 | ||||||||
| FaxNumber: | 7144562949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2017 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| AuthorizedOfficialLastName: | PORTO | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PERSIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 7144562986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM2500X | Y | Ambulatory Health Care Facilities | Clinic/Center | Medical Specialty |
No ID Information.