Provider Demographics
NPI:1083002075
Name:SOUTHERN CALIFORNIA PHYSICIAN NETWORK, INC
Entity type:Organization
Organization Name:SOUTHERN CALIFORNIA PHYSICIAN NETWORK, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:NDUATI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:951-200-7385
Mailing Address - Street 1:PO BOX 3046
Mailing Address - Street 2:
Mailing Address - City:MALVERN
Mailing Address - State:PA
Mailing Address - Zip Code:19355-0746
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2250 S MAIN ST STE 201
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-2536
Practice Address - Country:US
Practice Address - Phone:951-621-3232
Practice Address - Fax:951-882-6967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-30
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA307699OtherMEDICARE PIN
CA1083002075Medicaid