Basic Information
| Provider Information | |||||||||
| NPI: | 1558307173 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACKARD | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 26800 CROWN VALLEY PKWY STE 305 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926918017 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493646000 | ||||||||
| FaxNumber: | 9493643213 | ||||||||
| Practice Location | |||||||||
| Address1: | 26800 CROWN VALLEY PKWY | ||||||||
| Address2: | SUITE 250 | ||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926916384 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493640644 | ||||||||
| FaxNumber: | 9493641520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/21/2006 | ||||||||
| LastUpdateDate: | 11/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | A73876 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | GR0100620 | 05 | CA | MEDICAID |