Provider Demographics
NPI:1073026696
Name:OPTIMAL PHYSICIAN SURGICAL GROUP
Entity Type:Organization
Organization Name:OPTIMAL PHYSICIAN SURGICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:NEILESH
Authorized Official - Middle Name:
Authorized Official - Last Name:CHODADRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-596-1344
Mailing Address - Street 1:25067 JIM BRIDGER RD
Mailing Address - Street 2:
Mailing Address - City:HIDDEN HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91302-1128
Mailing Address - Country:US
Mailing Address - Phone:678-596-1344
Mailing Address - Fax:310-453-2535
Practice Address - Street 1:25067 JIM BRIDGER RD
Practice Address - Street 2:
Practice Address - City:HIDDEN HILLS
Practice Address - State:CA
Practice Address - Zip Code:91302-1128
Practice Address - Country:US
Practice Address - Phone:678-596-1344
Practice Address - Fax:310-453-2535
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-06
Last Update Date:2017-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA116169207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty