Provider Demographics
NPI:1386841278
Name:VISTA BAY MEDICAL GROUP
Entity Type:Organization
Organization Name:VISTA BAY MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JENS
Authorized Official - Middle Name:W
Authorized Official - Last Name:DIMMICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-540-6770
Mailing Address - Street 1:21320 HAWTHORNE BLVD
Mailing Address - Street 2:207
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-5606
Mailing Address - Country:US
Mailing Address - Phone:310-540-6770
Mailing Address - Fax:310-540-2004
Practice Address - Street 1:21320 HAWTHORNE BLVD
Practice Address - Street 2:207
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-5606
Practice Address - Country:US
Practice Address - Phone:310-540-6770
Practice Address - Fax:310-540-2004
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26557207R00000X
CAA22090207XX0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic TraumaGroup - Multi-Specialty