Provider Demographics
NPI:1942239694
Name:VISTA DEL MAR MEDICAL GROUP, INC
Entity Type:Organization
Organization Name:VISTA DEL MAR MEDICAL GROUP, INC
Other - Org Name:N/A
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:K
Authorized Official - Last Name:WESTERDOLL
Authorized Official - Suffix:
Authorized Official - Credentials:CAAMA, CMM
Authorized Official - Phone:805-983-0691
Mailing Address - Street 1:1200 W GONZALES RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-3072
Mailing Address - Country:US
Mailing Address - Phone:805-983-0691
Mailing Address - Fax:805-981-1643
Practice Address - Street 1:1200 W GONZALES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-3072
Practice Address - Country:US
Practice Address - Phone:805-983-0691
Practice Address - Fax:805-981-1643
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-02
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAFNP4189207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110039977OtherMEDICARE RAILROAD
CAZZZ75566ZMedicaid
CAZZZ34679ZOtherBLUE CROSS
CAW2039Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER