=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922008119
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SALAH SONBOL M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/28/2005
-----------------------------------------------------
Last Update Date | 06/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 227 W JANSS RD SUITE 100
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91360-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-496-6051
-----------------------------------------------------
Fax | 805-496-8532
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2160
-----------------------------------------------------
City | MOORPARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93020-2160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-842-9530
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | A55966
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------