Healthcare Provider Details

I. General information

NPI: 1124182365
Provider Name (Legal Business Name): JON NOTHWANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 07/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3291 LOMA VISTA RD
VENTURA CA
93003
US

IV. Provider business mailing address

3418 LOMA VISTA RD SUITE A
VENTURA CA
93003
US

V. Phone/Fax

Practice location:
  • Phone: 805-642-8565
  • Fax: 805-642-8564
Mailing address:
  • Phone: 805-642-8565
  • Fax: 805-642-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberG66219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: