Provider Demographics
NPI:1568414712
Name:DANSEREAU, JEAN JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:JOSEPH
Last Name:DANSEREAU
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 1:1040 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5092
Mailing Address - Country:US
Mailing Address - Phone:805-673-3930
Mailing Address - Fax:805-659-3217
Practice Address - Street 1:650 META ST
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7182
Practice Address - Country:US
Practice Address - Phone:805-487-5351
Practice Address - Fax:805-647-7164
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA0440312084P0800X
CO498572084P0800X
CAA440312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC71031FMedicaid
CAFHC03884FMedicaid
CAFHC70936FMedicaid
CAFHC70693FMedicaid
CAFHC03884FMedicaid
CA551983Medicare Oscar/Certification
CAW1508Medicare PIN
CA551904Medicare Oscar/Certification
CAW1508AMedicare PIN
CAFHC71031FMedicaid
CA051847Medicare Oscar/Certification
W1508Medicare PIN
CAW1508EMedicare PIN