1639656358 NPI number — MD24 OC, INC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639656358 NPI number — MD24 OC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MD24 OC, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1639656358
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/25/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PLAZA TOWER I 600 ANTON BLVD,
Provider Second Line Business Mailing Address:
SUITE 1100,
Provider Business Mailing Address City Name:
COSTA MESA
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
92626
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-374-7774
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PLAZA TOWER I 600 ANTON BLVD,
Provider Second Line Business Practice Location Address:
SUITE 1100,
Provider Business Practice Location Address City Name:
COSTA MESA
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
92626
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-374-7774
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/25/2018

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
NGUYEN
Authorized Official First Name:
LINH
Authorized Official Middle Name:
CAO
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
623-374-7774

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)