Provider Demographics
NPI:1376654756
Name:ADOBE MEDICAL GROUP INC
Entity Type:Organization
Organization Name:ADOBE MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KAMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHODSIAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-662-1515
Mailing Address - Street 1:24502 PACIFIC PARK DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3033
Mailing Address - Country:US
Mailing Address - Phone:949-362-1515
Mailing Address - Fax:949-362-7548
Practice Address - Street 1:31921 CAMINO CAPISTRANO
Practice Address - Street 2:SUITE 19
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-3210
Practice Address - Country:US
Practice Address - Phone:949-487-2323
Practice Address - Fax:949-487-3630
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0082570Medicaid
CAZZZ257218ZOtherBLUE SHIELD PROVIDER #
CAW15048Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER