1457698359 NPI number — DR. MARVIN WADE ALTOM PH.D

Table of content: DR. MARVIN WADE ALTOM PH.D (NPI 1457698359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457698359 NPI number — DR. MARVIN WADE ALTOM PH.D

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
ALTOM
Provider First Name:
MARVIN
Provider Middle Name:
WADE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PH.D
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1457698359
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
13676 SHENANDOAH WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOORPARK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93021-1262
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-341-0084
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5014 CHESEBRO RD FL 2
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AGOURA HILLS
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91301-2278
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
818-707-7366
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/11/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY 24619 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)