Provider Demographics
NPI:1912176728
Name:GEORGE O. DETARNOWSKY, JR M.D., INC.
Entity type:Organization
Organization Name:GEORGE O. DETARNOWSKY, JR M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:OLIVIER
Authorized Official - Last Name:DETARNOWSKY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:949-574-5026
Mailing Address - Street 1:355 PLACENTIA AVE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3311
Mailing Address - Country:US
Mailing Address - Phone:949-574-5026
Mailing Address - Fax:949-548-8893
Practice Address - Street 1:355 PLACENTIA AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3311
Practice Address - Country:US
Practice Address - Phone:949-574-5026
Practice Address - Fax:949-548-8893
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG41113305R00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA0332Medicare UPIN