Healthcare Provider Details

I. General information

NPI: 1013919208
Provider Name (Legal Business Name): LOS ROBLES PEDIATRIC MEDICAL GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 W HILLCREST DR STE 100
THOUSAND OAKS CA
91360-7820
US

IV. Provider business mailing address

299 W HILLCREST DR STE 100
THOUSAND OAKS CA
91360-7820
US

V. Phone/Fax

Practice location:
  • Phone: 805-497-7888
  • Fax: 805-494-3498
Mailing address:
  • Phone: 805-497-7888
  • Fax: 805-494-3498

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA22017
License Number StateCA

VIII. Authorized Official

Name: DR. MICHAEL GOLLUB
Title or Position: PRESIDENT
Credential: M.D.
Phone: 805-497-7888