Healthcare Provider Details

I. General information

NPI: 1750576880
Provider Name (Legal Business Name): EDAN YODFAT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/11/2007
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 S WELLS RD CLINICAS DEL CAMINO REAL
VENTURA CA
93004-1377
US

IV. Provider business mailing address

58 FAIRVIEW AVE
CLOSTER NJ
07624-1104
US

V. Phone/Fax

Practice location:
  • Phone: 805-659-1740
  • Fax:
Mailing address:
  • Phone: 805-659-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberA116190
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: