Provider Demographics
NPI:1740773787
Name:AMEZCUA, MIGUEL (DO)
Entity Type:Individual
Prefix:DR
First Name:MIGUEL
Middle Name:
Last Name:AMEZCUA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18937 PELHAM WAY
Mailing Address - Street 2:
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886-7006
Mailing Address - Country:US
Mailing Address - Phone:714-323-4076
Mailing Address - Fax:
Practice Address - Street 1:800 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-3420
Practice Address - Country:US
Practice Address - Phone:714-323-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-13
Last Update Date:2022-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA20A17655207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program