Provider Demographics
NPI:1942499793
Name:ENDOCRINOLOGY MEDICAL GROUP OF ORANGE COUNTY INC
Entity Type:Organization
Organization Name:ENDOCRINOLOGY MEDICAL GROUP OF ORANGE COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ON SITE OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BANKHARDT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-771-5700
Mailing Address - Street 1:725 W LA VETA AVE
Mailing Address - Street 2:220
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4403
Mailing Address - Country:US
Mailing Address - Phone:714-771-5700
Mailing Address - Fax:714-771-7797
Practice Address - Street 1:725 W LA VETA AVE
Practice Address - Street 2:220
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4403
Practice Address - Country:US
Practice Address - Phone:714-771-5700
Practice Address - Fax:714-771-7797
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-17
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG25017207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA42485Medicare UPIN
CAW6959Medicare PIN