Provider Demographics
NPI:1851339089
Name:MENCHACA, RAYMOND M (MD)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:M
Last Name:MENCHACA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2705 LOMA VISTA RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1581
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-667-2865
Practice Address - Street 1:852 W VENTURA ST
Practice Address - Street 2:
Practice Address - City:FILLMORE
Practice Address - State:CA
Practice Address - Zip Code:93015-1837
Practice Address - Country:US
Practice Address - Phone:805-524-2672
Practice Address - Fax:805-524-3953
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG75144207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1215903018OtherNPI
CA95-1683892OtherOTHER INSURANCE
CARHM08609FMedicaid
CARHM08608FMedicaid
CARHM18553HMedicaid
CAZZT40394FMedicaid
CA050394OtherBLUE CROSS
F73237Medicare UPIN
CA050394Medicare ID - Type UnspecifiedMEDICARE
CARHM08608FMedicaid
CA050394OtherBLUE CROSS
CA95-1683892OtherOTHER INSURANCE
CAG75144AMedicare ID - Type UnspecifiedPPIN