Provider Demographics
NPI:1174672794
Name:CITRUS VALLEY CARDIOLOGY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:CITRUS VALLEY CARDIOLOGY MEDICAL GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NEIL
Authorized Official - Middle Name:E
Authorized Official - Last Name:DOHERTY
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:626-857-7344
Mailing Address - Street 1:353 W FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91741-3359
Mailing Address - Country:US
Mailing Address - Phone:626-857-7344
Mailing Address - Fax:626-857-7340
Practice Address - Street 1:353 W FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91741-3359
Practice Address - Country:US
Practice Address - Phone:626-857-7344
Practice Address - Fax:626-857-7340
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2007-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0084810Medicaid
CAZZZ29233ZOtherBLUE SHIELD
CAGR0084810Medicaid
CACD7651Medicare ID - Type UnspecifiedRAILROAD MEDICARE