Healthcare Provider Details

I. General information

NPI: 1912960345
Provider Name (Legal Business Name): AGOURA FAMILY PRACTICE ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 06/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3180 WILLOW LN 102
THOUSAND OAKS CA
91361-4900
US

IV. Provider business mailing address

3180 WILLOW LN #102
THOUSAND OAKS CA
91361-4900
US

V. Phone/Fax

Practice location:
  • Phone: 805-494-8520
  • Fax: 805-557-0196
Mailing address:
  • Phone: 805-494-8520
  • Fax: 805-557-0196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberG069473
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA67631
License Number StateCA

VIII. Authorized Official

Name: DR. BADER IQBAL
Title or Position: OWNER PARTNER
Credential: MD
Phone: 805-494-8520