Provider Demographics
NPI:1154329266
Name:UROLOGIC MEDICAL GROUP OF NORTH ORANGE COUNTY
Entity Type:Organization
Organization Name:UROLOGIC MEDICAL GROUP OF NORTH ORANGE COUNTY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:SCOTT
Authorized Official - Last Name:GAZZANIGA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-870-5970
Mailing Address - Street 1:301 W BASTANCHURY RD
Mailing Address - Street 2:#180
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835
Mailing Address - Country:US
Mailing Address - Phone:714-830-5970
Mailing Address - Fax:714-870-4792
Practice Address - Street 1:301 W BASTANCHURY RD
Practice Address - Street 2:#180
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-830-5970
Practice Address - Fax:714-870-4792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65760208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW11198Medicare ID - Type Unspecified