Healthcare Provider Details

I. General information

NPI: 1720198385
Provider Name (Legal Business Name): DAVID GILLES DUFOUR PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16101 VENTURA BLVD SUITE 340
ENCINO CA
91436-2500
US

IV. Provider business mailing address

PO BOX 77790
CORONA CA
92877-0126
US

V. Phone/Fax

Practice location:
  • Phone: 818-788-7500
  • Fax: 818-380-9245
Mailing address:
  • Phone: 800-626-2468
  • Fax: 951-272-9924

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: