1073026696 NPI number — OPTIMAL PHYSICIAN SURGICAL GROUP

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 1073026696 NPI number — OPTIMAL PHYSICIAN SURGICAL GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OPTIMAL PHYSICIAN SURGICAL GROUP
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:
1073026696
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/06/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
25067 JIM BRIDGER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HIDDEN HILLS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91302-1128
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
678-596-1344
Provider Business Mailing Address Fax Number:
310-453-2535

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
25067 JIM BRIDGER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HIDDEN HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91302-1128
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-596-1344
Provider Business Practice Location Address Fax Number:
310-453-2535
Provider Enumeration Date:
11/06/2017

Additional Information

Authorized Official

Authorized Official Last Name:
CHODADRA
Authorized Official First Name:
NEILESH
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
678-596-1344

Provider Taxonomy Codes

  • Taxonomy code: 207XX0005X , with the licence number:  A116169 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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