Provider Demographics
NPI:1831294917
Name:VIVIAN, MICHAEL R P (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R P
Last Name:VIVIAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3311 OLD CONEJO RD
Mailing Address - Street 2:
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-2115
Mailing Address - Country:US
Mailing Address - Phone:805-388-3337
Mailing Address - Fax:805-388-1155
Practice Address - Street 1:3311 OLD CONEJO RD
Practice Address - Street 2:
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-2115
Practice Address - Country:US
Practice Address - Phone:805-388-3337
Practice Address - Fax:805-388-1155
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG788902084P0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G75963Medicare ID - Type Unspecified
CAG75963Medicare UPIN