1770050460 NPI number — ETHAN J. BAUGHMAN, M.D. INC., A MEDICAL CORPORATION

Table of content: (NPI 1770050460)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770050460 NPI number — ETHAN J. BAUGHMAN, M.D. INC., A MEDICAL CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ETHAN J. BAUGHMAN, M.D. INC., A MEDICAL CORPORATION
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:
1770050460
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1560 NEWBURY RD, STE 1 #179
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
THOUSAND OAKS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
972-413-9683
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
32144 AGOURA RD STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WESTLAKE VILLAGE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91361-4057
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-409-7537
Provider Business Practice Location Address Fax Number:
310-363-7610
Provider Enumeration Date:
10/31/2018

Additional Information

Authorized Official

Authorized Official Last Name:
BAUGHMAN
Authorized Official First Name:
ETHAN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
972-413-9683

Provider Taxonomy Codes

  • Taxonomy code: 2086S0122X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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