Provider Demographics
NPI:1912102161
Name:UC REGENTS SURGERY LASER UNIVERSITY PHY
Entity type:Organization
Organization Name:UC REGENTS SURGERY LASER UNIVERSITY PHY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:S
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-824-7526
Mailing Address - Street 1:PO BOX 513375
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90051-3375
Mailing Address - Country:US
Mailing Address - Phone:949-824-4269
Mailing Address - Fax:949-824-2726
Practice Address - Street 1:1002 HEALTH SCIENCES RD EAST
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-3010
Practice Address - Country:US
Practice Address - Phone:949-824-4269
Practice Address - Fax:949-824-2726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-18
Last Update Date:2008-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty