Provider Demographics
NPI:1679837645
Name:VENTURA COUNTY ANESTHESIA MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:VENTURA COUNTY ANESTHESIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE INCORPORATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-652-6000
Mailing Address - Street 1:3116 W MARCH LN
Mailing Address - Street 2:SUITE 200
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-2369
Mailing Address - Country:US
Mailing Address - Phone:209-473-6555
Mailing Address - Fax:209-473-6544
Practice Address - Street 1:3291 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-3099
Practice Address - Country:US
Practice Address - Phone:805-652-6000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-25
Last Update Date:2014-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1679837645Medicaid
CA1679837645Medicaid