Provider Demographics
NPI:1699962688
Name:PEDIATRIC MEDICAL ASSOCIATES OF ORANGE COUNTY INC
Entity type:Organization
Organization Name:PEDIATRIC MEDICAL ASSOCIATES OF ORANGE COUNTY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MAMERTO
Authorized Official - Middle Name:
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:714-520-0826
Mailing Address - Street 1:1211 W LA PALMA AVE
Mailing Address - Street 2:SUITE 401
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-2815
Mailing Address - Country:US
Mailing Address - Phone:714-520-0313
Mailing Address - Fax:714-520-0896
Practice Address - Street 1:1211 W LA PALMA AVE
Practice Address - Street 2:SUITE 401
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-2815
Practice Address - Country:US
Practice Address - Phone:714-520-0313
Practice Address - Fax:714-520-0896
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-03
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00A489170208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A489170Medicaid