Healthcare Provider Details

I. General information

NPI: 1124682745
Provider Name (Legal Business Name): GRIFFIN MICHAEL ELBERT DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2019
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 N BRENT ST
VENTURA CA
93003-2809
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 805-948-5672
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A19673
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number20A19673
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: