Provider Demographics
NPI:1972166452
Name:EAR NOSE THROAT MD INC.
Entity type:Organization
Organization Name:EAR NOSE THROAT MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BRAGANZA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:562-341-4786
Mailing Address - Street 1:2552 WALNUT AVE STE 130
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-6970
Mailing Address - Country:US
Mailing Address - Phone:714-847-9677
Mailing Address - Fax:
Practice Address - Street 1:2552 WALNUT AVE STE 130
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6970
Practice Address - Country:US
Practice Address - Phone:714-847-9677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty