Provider Demographics
NPI:1669470811
Name:THOUSAND OAKS CLINIC WORK MED
Entity Type:Organization
Organization Name:THOUSAND OAKS CLINIC WORK MED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:DENNIS
Authorized Official - Last Name:BLACKBURN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:210-490-1000
Mailing Address - Street 1:2235 THOUSAND OAKS DR
Mailing Address - Street 2:SUITE 115-117
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78232-3966
Mailing Address - Country:US
Mailing Address - Phone:210-490-1000
Mailing Address - Fax:210-490-3806
Practice Address - Street 1:2235 THOUSAND OAKS DR
Practice Address - Street 2:SUITE 115-117
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78232-3966
Practice Address - Country:US
Practice Address - Phone:210-490-1000
Practice Address - Fax:210-490-3806
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2008-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMDC7546174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00SN84Medicare PIN