Healthcare Provider Details

I. General information

NPI: 1831162213
Provider Name (Legal Business Name): DAVID MARK GUDEMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 JONES WAY SUITE 27B
SIMI VALLEY CA
93065
US

IV. Provider business mailing address

2650 JONES WAY SUITE 27B
SIMI VALLEY CA
93065
US

V. Phone/Fax

Practice location:
  • Phone: 805-582-4995
  • Fax: 805-582-4955
Mailing address:
  • Phone: 805-582-4995
  • Fax: 805-582-4955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberG69799
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: