Provider Demographics
NPI:1467461574
Name:FANG, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:FANG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3085 LOMA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2916
Mailing Address - Country:US
Mailing Address - Phone:805-648-3085
Mailing Address - Fax:805-648-7027
Practice Address - Street 1:3085 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2916
Practice Address - Country:US
Practice Address - Phone:805-648-3085
Practice Address - Fax:805-648-7027
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC54802207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC54802OtherCA MEDICAL LICENSE
OK200090320AMedicaid
CAF1916YMedicare PIN
OK246628502Medicare PIN
OK200090320AMedicaid
CAF1916ZMedicare PIN