Provider Demographics
NPI:1508823873
Name:COMMUNITY ORTHOPEDIC MEDICAL GROUP
Entity Type:Organization
Organization Name:COMMUNITY ORTHOPEDIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JERALD
Authorized Official - Middle Name:P
Authorized Official - Last Name:WALDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-348-4000
Mailing Address - Street 1:26401 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6350
Mailing Address - Country:US
Mailing Address - Phone:949-348-4000
Mailing Address - Fax:
Practice Address - Street 1:26401 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6350
Practice Address - Country:US
Practice Address - Phone:949-348-4000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-28
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42640207X00000X
CAG63599207X00000X
CAG69562207X00000X
CAG64377207X00000X
CAG74361207XS0106X
CAG25458207XS0117X
CAA70607207XS0117X
CAA108023207XX0004X
CAA64745208100000X
CAA80044208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
No207XX0004XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryFoot and Ankle SurgeryGroup - Multi-Specialty
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ24045ZOtherBLUE SHIELD
CA0827490001Medicare NSC
CAW1341Medicare PIN