1215591920 NPI number — VENTURA COUNTY PODIATRIC MEDICAL GROUP, INC

Table of content: (NPI 1215591920)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215591920 NPI number — VENTURA COUNTY PODIATRIC MEDICAL GROUP, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VENTURA COUNTY PODIATRIC MEDICAL GROUP, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1215591920
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1147
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VENTURA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93002-1147
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-485-6708
Provider Business Mailing Address Fax Number:
805-278-2299

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
451 W GONZALES RD STE 260
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93036-0729
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-485-6708
Provider Business Practice Location Address Fax Number:
805-278-2299
Provider Enumeration Date:
04/29/2019

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ROBERG
Authorized Official First Name:
SCOT
Authorized Official Middle Name:
LINDSEY
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
805-485-6708

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: E3640 . This is a "CA STATE LICENSE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".