Provider Demographics
NPI:1104960749
Name:S M MULTISPECIALTY MEDICAL CORPORATION
Entity type:Organization
Organization Name:S M MULTISPECIALTY MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MAPARA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:714-970-0911
Mailing Address - Street 1:2492 WALNUT AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6953
Mailing Address - Country:US
Mailing Address - Phone:714-669-1997
Mailing Address - Fax:714-573-7424
Practice Address - Street 1:2492 WALNUT AVE
Practice Address - Street 2:SUITE 110
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6953
Practice Address - Country:US
Practice Address - Phone:714-669-1997
Practice Address - Fax:714-573-7424
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8503207X00000X
CAA37744207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA37744OtherSTATE LICENSE
CAA28448Medicare UPIN