Provider Demographics
NPI:1669566790
Name:GARRETT, ROBERT JOHN
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JOHN
Last Name:GARRETT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3379 MONTAGNE WAY
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91362-4836
Mailing Address - Country:US
Mailing Address - Phone:805-492-4674
Mailing Address - Fax:805-492-1685
Practice Address - Street 1:3379 MONTAGNE WAY
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91362-4836
Practice Address - Country:US
Practice Address - Phone:805-492-4674
Practice Address - Fax:805-492-1685
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT25829174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT25829OtherMEDICARE PROVIDER NUMBER