Provider Demographics
NPI:1154525889
Name:MAGANDA, DEXTER
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:
Last Name:MAGANDA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 HAMMOND STE C
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-1680
Mailing Address - Country:US
Mailing Address - Phone:949-770-6022
Mailing Address - Fax:949-770-7084
Practice Address - Street 1:412 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-3685
Practice Address - Country:US
Practice Address - Phone:661-945-0884
Practice Address - Fax:661-942-9714
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29098225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMEDICARE PPINMedicare ID - Type UnspecifiedWPT29098F