Provider Demographics
NPI:1366753923
Name:TUSTIN IRVINE MEDICAL GROUP, INC
Entity type:Organization
Organization Name:TUSTIN IRVINE MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEVIZOS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:949-206-9100
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 301
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:
Practice Address - Street 1:15751 ROCKFIELD BLVD
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2832
Practice Address - Country:US
Practice Address - Phone:949-206-9100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TUSTIN IRVINE MEDICAL GROUP, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-06-29
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty