1104960749 NPI number — S M MULTISPECIALTY MEDICAL CORPORATION

Table of content: (NPI 1104960749)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104960749 NPI number — S M MULTISPECIALTY MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
S M MULTISPECIALTY MEDICAL CORPORATION
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:
6
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:
1104960749
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/17/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2492 WALNUT AVE
Provider Second Line Business Mailing Address:
SUITE 110
Provider Business Mailing Address City Name:
TUSTIN
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92780-6953
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
714-669-1997
Provider Business Mailing Address Fax Number:
714-573-7424

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2492 WALNUT AVE
Provider Second Line Business Practice Location Address:
SUITE 110
Provider Business Practice Location Address City Name:
TUSTIN
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92780-6953
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
714-669-1997
Provider Business Practice Location Address Fax Number:
714-573-7424
Provider Enumeration Date:
02/16/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MAPARA
Authorized Official First Name:
SUNIL
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
714-970-0911

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  20A8503 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: A37744 , 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)

  • Identifier: A37744 . This is a "STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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