Provider Demographics
NPI:1760681043
Name:PACIFIC MINIMALLY INVASIVE SURGEONS, INC
Entity Type:Organization
Organization Name:PACIFIC MINIMALLY INVASIVE SURGEONS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DUDZIAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-599-6784
Mailing Address - Street 1:1330 W COVINA BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3200
Mailing Address - Country:US
Mailing Address - Phone:909-599-6784
Mailing Address - Fax:909-599-7073
Practice Address - Street 1:1330 W COVINA BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3200
Practice Address - Country:US
Practice Address - Phone:909-599-6784
Practice Address - Fax:909-599-7073
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-16
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA87866208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8G0894OtherMEDICARE ID TYPE UNSPECIF
TX8G0894OtherMEDICARE ID TYPE UNSPECIF