Healthcare Provider Details

I. General information

NPI: 1962402180
Provider Name (Legal Business Name): MICHELE A GHAUSSY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 09/04/2024
Certification Date: 09/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 SCARBOROUGH ST
THOUSAND OAKS CA
91361-1346
US

IV. Provider business mailing address

PO BOX 1086
THOUSAND OAKS CA
91358-0086
US

V. Phone/Fax

Practice location:
  • Phone: 805-277-0789
  • Fax:
Mailing address:
  • Phone: 805-990-4375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG50708
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: