Provider Demographics
NPI:1972812139
Name:TUSTIN PLACE MEDICAL GROUP
Entity Type:Organization
Organization Name:TUSTIN PLACE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAYENDRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AMIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-838-8254
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:13095 JAMBOREE RD
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-9150
Practice Address - Country:US
Practice Address - Phone:714-838-8254
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUSTIN PLACE MEDICAL GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-10-05
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site