Provider Demographics
NPI:1013456979
Name:MALDONADO, SAMUEL JR (BOCO)
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:
Last Name:MALDONADO
Suffix:JR
Gender:M
Credentials:BOCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 N. HARBOR BLVD
Mailing Address - Street 2:SUITE 1200
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-3821
Mailing Address - Country:US
Mailing Address - Phone:714-871-9960
Mailing Address - Fax:714-871-9965
Practice Address - Street 1:2151 N. HARBOR BLVD
Practice Address - Street 2:SUITE 1200
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3821
Practice Address - Country:US
Practice Address - Phone:714-871-9960
Practice Address - Fax:714-871-9965
Is Sole Proprietor?:No
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50102222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist