Provider Demographics
NPI:1629061700
Name:ANTALL, INGRID WOELFL (MD)
Entity Type:Individual
Prefix:
First Name:INGRID
Middle Name:WOELFL
Last Name:ANTALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2755 ALAMO ST
Mailing Address - Street 2:STE 100
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1311
Mailing Address - Country:US
Mailing Address - Phone:805-210-7280
Mailing Address - Fax:805-210-7281
Practice Address - Street 1:2755 ALAMO ST
Practice Address - Street 2:STE 100
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1311
Practice Address - Country:US
Practice Address - Phone:805-210-7280
Practice Address - Fax:805-210-7281
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65624207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G82135Medicare UPIN