=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720198385
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID GILLES DUFOUR PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 02/27/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16101 VENTURA BLVD SUITE 340
-----------------------------------------------------
City | ENCINO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91436-2500
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-788-7500
-----------------------------------------------------
Fax | 818-380-9245
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 77790
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92877-0126
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-626-2468
-----------------------------------------------------
Fax | 951-272-9924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA12099
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------