Provider Demographics
NPI:1528220704
Name:DAVID M. GUDEMAN, M.D., INC.
Entity Type:Organization
Organization Name:DAVID M. GUDEMAN, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:GUDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MDL
Authorized Official - Phone:805-582-4995
Mailing Address - Street 1:2650 JONES WAY
Mailing Address - Street 2:SUITE 27B
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1203
Mailing Address - Country:US
Mailing Address - Phone:805-582-4995
Mailing Address - Fax:
Practice Address - Street 1:2650 JONES WAY
Practice Address - Street 2:SUITE 27B
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1203
Practice Address - Country:US
Practice Address - Phone:805-582-4995
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-27
Last Update Date:2008-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG69799101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG69799Medicare PIN
CAG55188Medicare UPIN