Healthcare Provider Details

I. General information

NPI: 1861770513
Provider Name (Legal Business Name): OCEANSIDE MEDICAL GROUP, A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/29/2011
Last Update Date: 07/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 SANTA MONICA BLVD SUITE 230
SANTA MONICA CA
90401-2623
US

IV. Provider business mailing address

701 SANTA MONICA BLVD SUITE 230
SANTA MONICA CA
90401-2623
US

V. Phone/Fax

Practice location:
  • Phone: 310-993-4103
  • Fax: 805-494-8385
Mailing address:
  • Phone: 310-993-4103
  • Fax: 805-494-8385

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: GADSON J JOHNSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 310-993-4103