Provider Demographics
NPI:1265458210
Name:NEWPORT DOCTORS MEDICAL GROUP INC
Entity type:Organization
Organization Name:NEWPORT DOCTORS MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:A
Authorized Official - Last Name:GEHRET
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-999-2977
Mailing Address - Street 1:401 OLD NEWPORT BLVD
Mailing Address - Street 2:STE 201
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4289
Mailing Address - Country:US
Mailing Address - Phone:949-999-2950
Mailing Address - Fax:949-999-2960
Practice Address - Street 1:401 OLD NEWPORT BLVD
Practice Address - Street 2:STE 201
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4289
Practice Address - Country:US
Practice Address - Phone:949-999-2950
Practice Address - Fax:949-999-2960
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-14
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48231174400000X
CAG39611174400000X
CAG23417174400000X
CAA33589174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW19467Medicare ID - Type Unspecified