Provider Demographics
NPI:1558456996
Name:FOSTAKOWSKY, ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:FOSTAKOWSKY
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 1:626 MESA DR
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010-1338
Mailing Address - Country:US
Mailing Address - Phone:805-983-3900
Mailing Address - Fax:805-983-3887
Practice Address - Street 1:451 W GONZALES RD
Practice Address - Street 2:SUITE 340
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-9004
Practice Address - Country:US
Practice Address - Phone:805-983-3900
Practice Address - Fax:805-983-3887
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA259052080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA24629Medicare UPIN