Provider Demographics
NPI:1740290634
Name:ALTA CALIFORNIA MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:ALTA CALIFORNIA MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALBERTO
Authorized Official - Middle Name:JOSE
Authorized Official - Last Name:ODIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-578-9620
Mailing Address - Street 1:2925 SYCAMORE DR
Mailing Address - Street 2:SUITE 204-205
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-1207
Mailing Address - Country:US
Mailing Address - Phone:805-578-9620
Mailing Address - Fax:805-955-0498
Practice Address - Street 1:2755 ALAMO ST STE 201
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-1311
Practice Address - Country:US
Practice Address - Phone:805-578-9620
Practice Address - Fax:805-955-0498
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-09
Last Update Date:2023-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3270701207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
W14981OtherMEDICARE PTAN