Healthcare Provider Details

I. General information

NPI: 1205516937
Provider Name (Legal Business Name): EDBAJAR RAMON VALDIVIESO RVT, RDCS, BS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2023
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 NEWBURY RD STE 270
THOUSAND OAKS CA
91320-6445
US

IV. Provider business mailing address

1000 NEWBURY RD
THOUSAND OAKS CA
91320-6435
US

V. Phone/Fax

Practice location:
  • Phone: 661-309-5037
  • Fax:
Mailing address:
  • Phone: 661-309-5037
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471S1302X
TaxonomySonography Radiologic Technologist
License Number102917
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number102917
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number102917
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License Number102917
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2471V0105X
TaxonomyVascular Sonography Radiologic Technologist
License Number102917
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License Number102917
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: