Provider Demographics
NPI:1053576876
Name:TUSTIN IRVINE MEDICAL GROUP, PC
Entity type:Organization
Organization Name:TUSTIN IRVINE MEDICAL GROUP, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:T
Authorized Official - Last Name:MALLAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:661-678-2626
Mailing Address - Street 1:25124 SPRINGFIELD CT
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91355-1085
Mailing Address - Country:US
Mailing Address - Phone:661-678-2600
Mailing Address - Fax:661-678-2700
Practice Address - Street 1:25124 SPRINGFIELD CT
Practice Address - Street 2:SUITE 200
Practice Address - City:VALENCIA
Practice Address - State:CA
Practice Address - Zip Code:91355-1085
Practice Address - Country:US
Practice Address - Phone:661-678-2600
Practice Address - Fax:661-678-2700
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:U.S. HEALTHWORKS MEDICAL GROUP, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-21
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CU798AOtherMEDICARE GROUP PTAN
F65818Medicare UPIN