Healthcare Provider Details

I. General information

NPI: 1699179762
Provider Name (Legal Business Name): CONEJO VALLEY MULTISPECIALTY MEDICAL GROUP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2014
Last Update Date: 10/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 W JANSS RD SUITE 110
THOUSAND OAKS CA
91360-1848
US

IV. Provider business mailing address

227 W JANSS RD SUITE 110
THOUSAND OAKS CA
91360-1848
US

V. Phone/Fax

Practice location:
  • Phone: 805-496-6051
  • Fax: 805-496-6785
Mailing address:
  • Phone: 805-496-6051
  • Fax: 805-496-6785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA23840
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA93280
License Number StateCA

VIII. Authorized Official

Name: DR. JIGAR GHELANI
Title or Position: PARTNER
Credential: M.D.
Phone: 805-496-6051