Basic Information
| Provider Information | |||||||||
| NPI: | 1740450378 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PEDIATRIC SLEEP, ADOPTION AND DEVELOPMENT CLINIC, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12315 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928598315 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5624244815 | ||||||||
| FaxNumber: | 5624244708 | ||||||||
| Practice Location | |||||||||
| Address1: | 4902 IRVINE CENTER DR STE 104 | ||||||||
| Address2: | |||||||||
| City: | IRVINE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926043334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494468990 | ||||||||
| FaxNumber: | 9494468535 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2008 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| AuthorizedOfficialLastName: | FELDMAN | ||||||||
| AuthorizedOfficialFirstName: | GARY | ||||||||
| AuthorizedOfficialMiddleName: | STEVEN | ||||||||
| AuthorizedOfficialTitleorPosition: | MEDICAL DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 5624244815 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 173F00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Other Service Providers | Sleep Specialist, PhD | 2080P0006X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Developmental – Behavioral Pediatrics | 2080S0012X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | Sleep Medicine | 207QS1201X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | Sleep Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A866560 | 05 | CA | MEDICAID |