Provider Demographics
NPI:1356328330
Name:NEWPORT CHILDREN'S MEDICAL GROUP
Entity Type:Organization
Organization Name:NEWPORT CHILDREN'S MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DERON
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLIARD
Authorized Official - Suffix:
Authorized Official - Credentials:CMPE
Authorized Official - Phone:949-644-0970
Mailing Address - Street 1:1401 AVOCADO AVE
Mailing Address - Street 2:#802
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7720
Mailing Address - Country:US
Mailing Address - Phone:949-644-0970
Mailing Address - Fax:949-644-0774
Practice Address - Street 1:1401 AVOCADO AVE
Practice Address - Street 2:#802
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7720
Practice Address - Country:US
Practice Address - Phone:949-644-0970
Practice Address - Fax:949-644-0774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-29
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083892Medicaid
CAGR0083890Medicaid