Provider Demographics
NPI:1598754780
Name:CHANNEL ISLAND OBSTETRICS AND GYNECOLOGIC MEDICAL GROUP
Entity Type:Organization
Organization Name:CHANNEL ISLAND OBSTETRICS AND GYNECOLOGIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL PARTNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:P
Authorized Official - Last Name:CARTER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-482-4641
Mailing Address - Street 1:2486 PONDEROSA DR NORTH STE D202
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93010
Mailing Address - Country:US
Mailing Address - Phone:805-482-4641
Mailing Address - Fax:805-388-8751
Practice Address - Street 1:2486 PONDEROSA DR NORTH STE D202
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010
Practice Address - Country:US
Practice Address - Phone:805-482-4641
Practice Address - Fax:805-388-8751
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0087730Medicaid
CAGR0087730Medicaid