Healthcare Provider Details

I. General information

NPI: 1366474819
Provider Name (Legal Business Name): PHILIP ENTE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 06/08/2021
Certification Date: 06/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 E OCEAN AVE SUITE 4A
LOMPOC CA
93436-7076
US

IV. Provider business mailing address

1111 E OCEAN AVE SUITE 4A
LOMPOC CA
93436-7076
US

V. Phone/Fax

Practice location:
  • Phone: 805-735-7623
  • Fax: 805-735-7224
Mailing address:
  • Phone: 805-735-7623
  • Fax: 805-735-7224

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberA42029
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00A420290
Identifier TypeMEDICAID
Identifier StateCA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: