Basic Information
| Provider Information | |||||||||
| NPI: | 1629454335 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UC IRVINE MEDICAL GROUP- TUSTIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 513980 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900513980 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7144566431 | ||||||||
| FaxNumber: | 7144567754 | ||||||||
| Practice Location | |||||||||
| Address1: | 1451 IRVINE BLVD | ||||||||
| Address2: | |||||||||
| City: | TUSTIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927803804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149388897 | ||||||||
| FaxNumber: | 7148388988 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/04/2015 | ||||||||
| LastUpdateDate: | 08/04/2015 | ||||||||
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| AuthorizedOfficialLastName: | PORTO | ||||||||
| AuthorizedOfficialFirstName: | MANUEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7144562986 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | REGENTS OF THE UNIVERSITY OF CALIFORNIA | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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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.