Provider Demographics
NPI:1619316783
Name:BAUGHMAN, ETHAN (MD PHD)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:
Last Name:BAUGHMAN
Suffix:
Gender:M
Credentials:MD PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1560 NEWBURY RD STE 1
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91320-3448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:32144 AGOURA RD STE 220
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-4057
Practice Address - Country:US
Practice Address - Phone:805-409-7537
Practice Address - Fax:310-363-7610
Is Sole Proprietor?:No
Enumeration Date:2013-06-21
Last Update Date:2020-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013020089208200000X
CAA158793208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200062362Medicaid