Provider Demographics
NPI:1407639941
Name:SENIOR DOC ID MEDICAL, PC
Entity Type:Organization
Organization Name:SENIOR DOC ID MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GEISS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:855-434-7763
Mailing Address - Street 1:2592 N SANTIAGO BLVD
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92867-1862
Mailing Address - Country:US
Mailing Address - Phone:855-434-7763
Mailing Address - Fax:949-281-5550
Practice Address - Street 1:2592 N SANTIAGO BLVD
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92867-1862
Practice Address - Country:US
Practice Address - Phone:855-434-7763
Practice Address - Fax:949-281-5550
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty