Healthcare Provider Details

I. General information

NPI: 1982823688
Provider Name (Legal Business Name): DAVID RANDALL HANTKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

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

IV. Provider business mailing address

2807 LOMA VISTA RD SUITE 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:
Title or Position:
Credential:
Phone: