Provider Demographics
NPI:1033305834
Name:NEWPORT BEACH COMPREHENSIVE CARE MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:NEWPORT BEACH COMPREHENSIVE CARE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:FONDREN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-574-1091
Mailing Address - Street 1:3419 VIA LIDO
Mailing Address - Street 2:PMB 349
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3908
Mailing Address - Country:US
Mailing Address - Phone:949-574-1091
Mailing Address - Fax:949-574-1097
Practice Address - Street 1:355 PLACENTIA AVE
Practice Address - Street 2:SUITE 102
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3311
Practice Address - Country:US
Practice Address - Phone:949-574-1091
Practice Address - Fax:949-574-1097
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-15
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60586207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG75962Medicare UPIN