Healthcare Provider Details

I. General information

NPI: 1558041590
Provider Name (Legal Business Name): DR. SALLY PEDIATRICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2023
Last Update Date: 07/24/2023
Certification Date: 07/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 LOMA VISTA RD
VENTURA CA
93003-3026
US

IV. Provider business mailing address

25 VIA MAGNOLIA
NEWBURY PARK CA
91320-6966
US

V. Phone/Fax

Practice location:
  • Phone: 805-918-1876
  • Fax:
Mailing address:
  • Phone: 805-217-5644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: SALLY J SMITH
Title or Position: OWNER/ PRESIDENT
Credential: MD
Phone: 805-918-1876