Healthcare Provider Details

I. General information

NPI: 1710202445
Provider Name (Legal Business Name): DAVID BJELICA, M.D. A MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2010
Last Update Date: 04/06/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MARIN ST STE. 120
THOUSAND OAKS CA
91360-4236
US

IV. Provider business mailing address

555 MARIN ST STE. 120
THOUSAND OAKS CA
91360-4236
US

V. Phone/Fax

Practice location:
  • Phone: 805-449-1111
  • Fax: 805-449-1136
Mailing address:
  • Phone: 805-449-1111
  • Fax: 805-449-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberA91484
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID BJELICA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 805-449-1111