Provider Demographics
NPI:1548340045
Name:GASTROINTESTINAL & LIVER DISEASES OF NEWPORT, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:GASTROINTESTINAL & LIVER DISEASES OF NEWPORT, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EUGENE
Authorized Official - Middle Name:R
Authorized Official - Last Name:PANTANGCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-840-8419
Mailing Address - Street 1:PO BOX 9409
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92658-9409
Mailing Address - Country:US
Mailing Address - Phone:626-840-8419
Mailing Address - Fax:949-705-6774
Practice Address - Street 1:1525 SUPERIOR AVE
Practice Address - Street 2:STE 208
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3639
Practice Address - Country:US
Practice Address - Phone:626-840-8419
Practice Address - Fax:949-705-6774
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-17
Last Update Date:2009-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA74336207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A744360Medicaid
CA00A744360Medicaid
CAW19081Medicare ID - Type Unspecified