Healthcare Provider Details

I. General information

NPI: 1891992095
Provider Name (Legal Business Name): ANDREW BOURGEOIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2007
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2975 SYCAMORE DR
SIMI VALLEY CA
93065-1201
US

IV. Provider business mailing address

2975 SYCAMORE DR
SIMI VALLEY CA
93065-1201
US

V. Phone/Fax

Practice location:
  • Phone: 805-955-6100
  • Fax:
Mailing address:
  • Phone: 805-955-6100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA111526
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD60237865
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301090563
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: