Provider Demographics
NPI:1992211809
Name:GARRETT WIRTH MD PROFESSIONAL
Entity Type:Organization
Organization Name:GARRETT WIRTH MD PROFESSIONAL
Other - Org Name:WIRTH PLASTIC SURGERY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARRETT
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-706-9988
Mailing Address - Street 1:1401 AVOCADO AVE STE 810
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-8708
Mailing Address - Country:US
Mailing Address - Phone:949-706-9988
Mailing Address - Fax:949-679-9967
Practice Address - Street 1:1401 AVOCADO AVE STE 810
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-8708
Practice Address - Country:US
Practice Address - Phone:949-706-9988
Practice Address - Fax:949-679-9967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-15
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA81620208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty