Provider Demographics
NPI:1376819623
Name:VENTURA PODIATRY GROUP INC
Entity Type:Organization
Organization Name:VENTURA PODIATRY GROUP INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDOLPH
Authorized Official - Middle Name:WARD
Authorized Official - Last Name:NORDYKE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:805-650-8333
Mailing Address - Street 1:4080 LOMA ROAD
Mailing Address - Street 2:SUITE D
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1811
Mailing Address - Country:US
Mailing Address - Phone:805-650-8333
Mailing Address - Fax:805-650-8382
Practice Address - Street 1:4080 LOMA VISTA RD
Practice Address - Street 2:SUITE #D
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1811
Practice Address - Country:US
Practice Address - Phone:805-650-8333
Practice Address - Fax:805-650-8382
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-30
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4245213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4245OtherSTATE PTAN