Healthcare Provider Details

I. General information

NPI: 1013195965
Provider Name (Legal Business Name): PODESTA ORTHOPEDIC & SPORTS MEDICINE INSTITUTE, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

351 ROLLING OAKS DR SUITE 104
THOUSAND OAKS CA
91361-1275
US

IV. Provider business mailing address

351 ROLLING OAKS DR SUITE 104
THOUSAND OAKS CA
91361-1275
US

V. Phone/Fax

Practice location:
  • Phone: 805-491-4008
  • Fax:
Mailing address:
  • Phone: 805-491-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberA46655
License Number StateCA

VIII. Authorized Official

Name: LUGA PODESTA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 805-491-4008