Provider Demographics
NPI:1154765709
Name:NEWPORT CHILDREN MEDICAL GROUP AT MISSION
Entity type:Organization
Organization Name:NEWPORT CHILDREN MEDICAL GROUP AT MISSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:JOHANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODRIGUEZ-TOLEDO
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:949-364-8700
Mailing Address - Street 1:26800 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE 510
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-364-8700
Mailing Address - Fax:949-365-1011
Practice Address - Street 1:26800 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE 510
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-6384
Practice Address - Country:US
Practice Address - Phone:949-364-8700
Practice Address - Fax:949-365-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-25
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA109148208000000X
CAA479472080P0203X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080P0203XAllopathic & Osteopathic PhysiciansPediatricsPediatric Critical Care MedicineGroup - Multi-Specialty