Provider Demographics
NPI:1356343172
Name:DAVID R. HANTKE, M.D., INC.
Entity type:Organization
Organization Name:DAVID R. HANTKE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANTKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-648-7222
Mailing Address - Street 1:2807 LOMA VISTA RD
Mailing Address - Street 2:STE 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:STE 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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-11
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG48701207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWG48701COtherMEDICARE INDIVIDUAL PTAN
CA00G487010OtherBLUE SHIELD
CADH0826OtherGROUP RAILROAD MEDICARE NUMBER
CAG48701OtherBLUE CROSS
CA00G487010Medicaid
CA040014777OtherRAILROAD MEDICARE
CA06B6953OtherTRICARE
CA00G487010Medicaid
CA06B6953OtherTRICARE