Provider Demographics
NPI:1588635890
Name:ADDO, EMMANUEL JUSTICE (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:JUSTICE
Last Name:ADDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 N TUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92705-3807
Mailing Address - Country:US
Mailing Address - Phone:800-883-7243
Mailing Address - Fax:714-647-1245
Practice Address - Street 1:20301 SW BIRCH ST STE 102
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1754
Practice Address - Country:US
Practice Address - Phone:949-251-1502
Practice Address - Fax:714-647-1245
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2015-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA83783207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A837830Medicaid
CAP00173501Medicare PIN
CAFQ509ZMedicare PIN
CAWA83783AMedicare PIN
CA00A837830Medicaid
CACB243637Medicare PIN
CAWA83783CMedicare PIN
CAWA83783BMedicare PIN