Healthcare Provider Details

I. General information

NPI: 1790967404
Provider Name (Legal Business Name): INTERNAL MEDICINE & PEDIATRICS PRIVATE PRACTICE, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3687 LAS POSAS RD SUITE H-187
CAMARILLO CA
93010-1482
US

IV. Provider business mailing address

3687 LAS POSAS RD SUITE H-187
CAMARILLO CA
93010-1482
US

V. Phone/Fax

Practice location:
  • Phone: 805-445-4189
  • Fax: 805-445-9219
Mailing address:
  • Phone: 805-445-4189
  • Fax: 805-445-9219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA053595
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA053595
License Number StateCA

VIII. Authorized Official

Name: DR. RAGU NATHAN
Title or Position: MANAGER
Credential: J.D.
Phone: 818-671-7700