Provider Demographics
NPI:1619152550
Name:FULLERTON ORTHOPAEDIC SURGERY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:FULLERTON ORTHOPAEDIC SURGERY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEWART
Authorized Official - Middle Name:L
Authorized Official - Last Name:SHANFIELD
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-879-0050
Mailing Address - Street 1:17021 YORBA LINDA BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-3715
Mailing Address - Country:US
Mailing Address - Phone:714-996-6440
Mailing Address - Fax:714-996-5831
Practice Address - Street 1:17021 YORBA LINDA BLVD STE 100
Practice Address - Street 2:
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-3715
Practice Address - Country:US
Practice Address - Phone:714-996-6440
Practice Address - Fax:714-996-5831
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2009-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG45883174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW1365OtherMEDICARE ID - TYPE UNSPECIFIED
CAW1365OtherMEDICARE ID - TYPE UNSPECIFIED