Healthcare Provider Details

I. General information

NPI: 1992753842
Provider Name (Legal Business Name): PHILLIP BRADLEY PLOTZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 09/19/2025
Certification Date: 09/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

699 W TEFFT ST SUITE A
NIPOMO CA
93444-9289
US

IV. Provider business mailing address

3400 DATA DR 1ST
RANCHO CORDOVA CA
95670-7956
US

V. Phone/Fax

Practice location:
  • Phone: 805-930-9995
  • Fax: 805-929-5771
Mailing address:
  • Phone: 916-379-2726
  • Fax: 916-853-7874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number202213900
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA063826
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number049327
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: