Provider Demographics
NPI:1811014319
Name:LAGUNA TIDES MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:LAGUNA TIDES MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:V
Authorized Official - Last Name:ELLER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-499-1337
Mailing Address - Street 1:30131 TOWN CENTER DR
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2034
Mailing Address - Country:US
Mailing Address - Phone:949-499-1337
Mailing Address - Fax:949-499-4962
Practice Address - Street 1:30131 TOWN CENTER DR
Practice Address - Street 2:SUITE 215
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2034
Practice Address - Country:US
Practice Address - Phone:949-499-1337
Practice Address - Fax:949-499-4962
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-22
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9817207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW21605Medicare PIN