Provider Demographics
NPI:1417988379
Name:INLAND EMPIRE GASTROENTEROLOGY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:INLAND EMPIRE GASTROENTEROLOGY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOEL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WITTLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-600-0288
Mailing Address - Street 1:40404 CALIFORNIA OAKS RD
Mailing Address - Street 2:SUITE C
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-5786
Mailing Address - Country:US
Mailing Address - Phone:951-600-0288
Mailing Address - Fax:951-600-0188
Practice Address - Street 1:40404 CALIFORNIA OAKS RD
Practice Address - Street 2:SUITE C
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92562-5786
Practice Address - Country:US
Practice Address - Phone:951-600-0288
Practice Address - Fax:951-600-0188
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48314174400000X
CAG75943174400000X
CAG43641174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA92430Medicare UPIN
CAF77405Medicare UPIN
CA00G436410Medicare ID - Type UnspecifiedMEDICARE NUMBER
CAA51003Medicare UPIN
CA00G759430Medicare ID - Type UnspecifiedMEDICARE NUMBER
CA00G483140Medicare ID - Type UnspecifiedMEDICARE NUMBER