Healthcare Provider Details

I. General information

NPI: 1356343172
Provider Name (Legal Business Name): DAVID R. HANTKE, M.D., INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2005
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2807 LOMA VISTA RD STE 103
VENTURA CA
93003-1500
US

IV. Provider business mailing address

2807 LOMA VISTA RD STE 103
VENTURA CA
93003-1500
US

V. Phone/Fax

Practice location:
  • Phone: 805-648-7222
  • Fax: 805-648-7235
Mailing address:
  • Phone: 805-648-7222
  • Fax: 805-648-7235

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License NumberG48701
License Number StateCA

VIII. Authorized Official

Name: DR. DAVID R HANTKE
Title or Position: PRESIDENT
Credential:
Phone: 805-648-7222