Healthcare Provider Details

I. General information

NPI: 1114570082
Provider Name (Legal Business Name): PLEASANT VALLEY PEDIATRIC MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2019
Last Update Date: 07/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2486 N PONDEROSA DR STE D211
CAMARILLO CA
93010-2470
US

IV. Provider business mailing address

2486 N PONDEROSA DR STE D211
CAMARILLO CA
93010-2470
US

V. Phone/Fax

Practice location:
  • Phone: 805-484-2818
  • Fax:
Mailing address:
  • Phone: 805-484-2818
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT VASKO
Title or Position: PEDIATRICIAN
Credential: MD
Phone: 805-368-0836