Healthcare Provider Details

I. General information

NPI: 1043255797
Provider Name (Legal Business Name): STEPHANUS R PHILIP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2006
Last Update Date: 07/17/2023
Certification Date: 07/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3291 LOMA VISTA RD
VENTURA CA
93003-3099
US

IV. Provider business mailing address

3291 LOMA VISTA RD
VENTURA CA
93003-3099
US

V. Phone/Fax

Practice location:
  • Phone: 805-652-6075
  • Fax: 805-652-6286
Mailing address:
  • Phone: 805-652-6075
  • Fax: 805-652-6286

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA87363
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA87363
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberA87363
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: