Provider Demographics
NPI:1962575068
Name:MISSION VIEJO FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:MISSION VIEJO FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:SCOT
Authorized Official - Last Name:ZIMMERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-588-8775
Mailing Address - Street 1:27001 LA PAZ RD
Mailing Address - Street 2:SUITE #294
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-5502
Mailing Address - Country:US
Mailing Address - Phone:949-588-8775
Mailing Address - Fax:949-588-9005
Practice Address - Street 1:27001 LA PAZ RD
Practice Address - Street 2:SUITE #294
Practice Address - City:MISSION VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92691-5502
Practice Address - Country:US
Practice Address - Phone:949-588-8775
Practice Address - Fax:949-588-9005
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-16
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA44517261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0042990Medicaid
CAZZZ06326ZOtherBLUE SHIELD OF CA
CAZZZ06326ZOtherBLUE SHIELD OF CA
CAGR0042990Medicaid