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NPI Code Detail

MEDICARE: LOS ROBLES PEDIATRIC MEDICAL GROUP, INC.

MEDICARE: LOS ROBLES PEDIATRIC MEDICAL GROUP, INC.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1208000000XPediatrics PhysicianA22017CA

General Provider Information

NPI Number : 1013919208
Entity Type Code : Organization
Provider Name (Legal Business Name) : LOS ROBLES PEDIATRIC MEDICAL GROUP, INC.
Provider Business Mailing Address
First Line : 299 W HILLCREST DR
Second Line : STE 100
City : THOUSAND OAKS
State : CA
Zip : 91360-7820
Country : US
Telephone Number : 805-497-7888
Fax Number : 805-494-3498
Provider Business Practice Location Address
First Line : 299 W HILLCREST DR
Second Line : STE 100
City : THOUSAND OAKS
State : CA
Zip : 91360-7820
Country : US
Telephone Number : 805-497-7888
Fax Number : 805-494-3498
Authorized Official
Title or Position : PRESIDENT
Name : DR. MICHAEL GOLLUB
Credential : M.D.
Telephone Number : 805-497-7888
Provider Enumeration Date : 06/01/2005
Last Update Date : 08/22/2020

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Directions to “LOS ROBLES PEDIATRIC MEDICAL GROUP, INC. ” Practice Location

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