1053508721 NPI number — GARY M VAN DEVENTER MD

Table of content: (NPI 1053508721)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053508721 NPI number — GARY M VAN DEVENTER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GARY M VAN DEVENTER MD
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:
1053508721
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 50706
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SANTA BARBARA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93150-0706
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-963-3336
Provider Business Mailing Address Fax Number:
805-564-3332

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
221 W PUEBLO ST
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
SANTA BARBARA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93105-6814
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-563-0024
Provider Business Practice Location Address Fax Number:
805-563-1454
Provider Enumeration Date:
09/26/2007

Additional Information

Authorized Official

Authorized Official Last Name:
VAN DEVENTER
Authorized Official First Name:
GARY
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
805-963-3336

Provider Taxonomy Codes

  • Taxonomy code: 207RG0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100004009 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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