Provider Demographics
NPI:1023354982
Name:JUAN CARLOS QUIROS MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:JUAN CARLOS QUIROS MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:CARLOS
Authorized Official - Last Name:QUIROS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-591-0456
Mailing Address - Street 1:675 N EUCLID ST
Mailing Address - Street 2:#628
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-4639
Mailing Address - Country:US
Mailing Address - Phone:714-591-0456
Mailing Address - Fax:714-591-0456
Practice Address - Street 1:1735 W ROMNEYA DR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-1804
Practice Address - Country:US
Practice Address - Phone:714-591-0456
Practice Address - Fax:888-508-0709
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-21
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45774174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWA45774CMedicare PIN
CAHK459YMedicare PIN