Provider Demographics
NPI:1548365786
Name:MISSION OB/GYN MEDICAL GROUP, INC
Entity type:Organization
Organization Name:MISSION OB/GYN MEDICAL GROUP, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:D
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-364-1040
Mailing Address - Street 1:26800 CROWN VALLEY PKWY
Mailing Address - Street 2:STE 525
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-6384
Mailing Address - Country:US
Mailing Address - Phone:949-364-1040
Mailing Address - Fax:949-365-7037
Practice Address - Street 1:665 CAMINO DE LOS MARES
Practice Address - Street 2:STE 303-A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92673-2859
Practice Address - Country:US
Practice Address - Phone:949-364-1040
Practice Address - Fax:949-365-7037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0071231Medicaid
CAGR0071231Medicaid