Provider Demographics
NPI:1689271389
Name:ANGEL FULLERTON MEDICAL GROUP
Entity Type:Organization
Organization Name:ANGEL FULLERTON MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GERARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:CANCHOLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-662-7710
Mailing Address - Street 1:1125 W ORANGETHORPE AVE
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-4735
Mailing Address - Country:US
Mailing Address - Phone:714-870-1888
Mailing Address - Fax:
Practice Address - Street 1:1125 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4735
Practice Address - Country:US
Practice Address - Phone:714-870-1888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-06
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1639185879OtherGENERAL PRACTICE
CA1720399843OtherGENERAL PRACTICE