Healthcare Provider Details

I. General information

NPI: 1073680336
Provider Name (Legal Business Name): JEROLD ANTHONY NOAH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/29/2006
Last Update Date: 02/19/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

825 N 10TH ST
SANTA PAULA CA
93060-1309
US

IV. Provider business mailing address

5641 STANFORD ST
VENTURA CA
93003-4244
US

V. Phone/Fax

Practice location:
  • Phone: 805-933-8600
  • Fax:
Mailing address:
  • Phone: 805-654-0271
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA83320
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: