Healthcare Provider Details

I. General information

NPI: 1366610024
Provider Name (Legal Business Name): THOUSAND OAKS ORTHOPEADIC GROUP INC P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/15/2008
Last Update Date: 02/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 HAALAND DR SUITE 101
THOUSAND OAKS CA
91361
US

IV. Provider business mailing address

425 HAALAND DR SUITE 101
THOUSAND OAKS CA
91361
US

V. Phone/Fax

Practice location:
  • Phone: 602-298-2653
  • Fax: 602-298-2686
Mailing address:
  • Phone: 602-298-2653
  • Fax: 602-298-2686

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberC27645
License Number StateCA

VIII. Authorized Official

Name: MR. ALEXANDER HERSEL
Title or Position: PARTNER
Credential: MD
Phone: 602-298-2653