Provider Demographics
NPI:1003955519
Name:GARCIA-NIQUE, LUIS OBISPO (MD)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:OBISPO
Last Name:GARCIA-NIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3010 W ORANGE AVE
Mailing Address - Street 2:SUITE # 2
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92804-3171
Mailing Address - Country:US
Mailing Address - Phone:714-527-8827
Mailing Address - Fax:714-527-0208
Practice Address - Street 1:3010 W ORANGE AVE
Practice Address - Street 2:SUITE # 2
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-3169
Practice Address - Country:US
Practice Address - Phone:714-527-8827
Practice Address - Fax:714-527-0208
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33647174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A336470Medicaid
CAC35420Medicare ID - Type UnspecifiedMEDICARE ID NUMBER
CAA33647Medicare UPIN