Provider Demographics
NPI:1194940015
Name:LEPORT SURGICAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:LEPORT SURGICAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETER
Authorized Official - Middle Name:CARY
Authorized Official - Last Name:LEPORT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:714-861-4666
Mailing Address - Street 1:18111 BROOKHURST ST
Mailing Address - Street 2:SUITE 5600
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-6728
Mailing Address - Country:US
Mailing Address - Phone:714-861-4666
Mailing Address - Fax:714-861-4682
Practice Address - Street 1:18111 BROOKHURST ST
Practice Address - Street 2:SUITE 5600
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-6728
Practice Address - Country:US
Practice Address - Phone:714-861-4666
Practice Address - Fax:714-916-5534
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-16
Last Update Date:2012-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG47193174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G471930Medicaid
CAW15023Medicare ID - Type UnspecifiedGROUP#
CAB57869Medicare UPIN