Provider Demographics
NPI:1326384512
Name:IDENTITY MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:IDENTITY MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEUTSCH,
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-256-7810
Mailing Address - Street 1:751 E DAILY DR
Mailing Address - Street 2:SUITE 120
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-6076
Mailing Address - Country:US
Mailing Address - Phone:805-256-7810
Mailing Address - Fax:805-256-7840
Practice Address - Street 1:751 E DAILY DR
Practice Address - Street 2:SUITE 120
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-6076
Practice Address - Country:US
Practice Address - Phone:805-256-7810
Practice Address - Fax:805-256-7840
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-17
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHD743AMedicare PIN
CAHD754ZMedicare PIN