MEDICARE: ONCOLOGY THERAPIES OF VISTA 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
1	261QX0203X	Radiation Oncology Clinic/Center		CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1265509657
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ONCOLOGY THERAPIES OF VISTA MEDICAL GROUP, INC

Provider Business Mailing Address
First Line	:	916 SYCAMORE AVE
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92081-7815
Country	:	US
Telephone Number	:	760-599-9545
Fax Number	:	760-599-9549

Provider Business Practice Location Address
First Line	:	916 SYCAMORE AVE
Second Line	:
City	:	VISTA
State	:	CA
Zip	:	92081-7815
Country	:	US
Telephone Number	:	760-599-9545
Fax Number	:	760-599-9549

Authorized Official
Title or Position	:	MANAGER
Name	:	ELIZABETH N BOURBEAU
Credential	:
Telephone Number	:	760-599-9545

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	01/08/2008

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