Healthcare Provider Details

I. General information

NPI: 1629061700
Provider Name (Legal Business Name): INGRID WOELFL ANTALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 09/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2755 ALAMO ST STE 100
SIMI VALLEY CA
93065-1311
US

IV. Provider business mailing address

2755 ALAMO ST STE 100
SIMI VALLEY CA
93065-1311
US

V. Phone/Fax

Practice location:
  • Phone: 805-210-7280
  • Fax: 805-210-7281
Mailing address:
  • Phone: 805-210-7280
  • Fax: 805-210-7281

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA65624
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: