Provider Demographics
NPI:1982823688
Name:HANTKE, DAVID RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:RANDALL
Last Name:HANTKE
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 1:2807 LOMA VISTA RD
Mailing Address - Street 2:SUITE 103
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-1500
Mailing Address - Country:US
Mailing Address - Phone:805-648-7222
Mailing Address - Fax:805-648-7235
Practice Address - Street 1:2807 LOMA VISTA RD
Practice Address - Street 2:SUITE 103
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-1500
Practice Address - Country:US
Practice Address - Phone:805-648-7222
Practice Address - Fax:805-648-7235
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48701207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G487010Medicaid
CA00G487010OtherBLUE SHIELD
CA040014777OtherRAILROAD MEDICARE
CAWG48701COtherINDIVIDUAL MEDICARE PTAN
CA06B6953OtherTRICARE
CADH0826OtherGROUP RAILROAD MEDICARE NUMBER
CAG48701OtherBLUE CROSS
CAG48701OtherBLUE CROSS
CADH0826OtherGROUP RAILROAD MEDICARE NUMBER
CAWG48701COtherINDIVIDUAL MEDICARE PTAN