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Provider Information for 1225083876

Please Note: Issuance of an NPI does not ensure or validate that the Health Care Provider is Licensed or Credentialed. For more information please refer to NPI: What You Need to Know


Gender: MALE

Individual NPI: 1225083876

Calendar   Last Updated:  2015-11-10
  Certification Date: 


Name Value
NPI 1225083876
Enumeration Date 2006-05-23
NPI Type 1 - Individual
Sole Proprietor YES
Status Active
Mailing Address PO BOX 62106
SANTA BARBARA, CA 93160-2106
United States

Phone: 805-737-8700 | Fax: 805-737-8700
View Map External Link
Primary Practice Address 1225 N H ST
LOMPOC, CA 93436-3301
United States

Phone: 805-737-8700 | Fax: 805-737-8704
View Map External Link
Health Information Exchange
Endpoint Type Endpoint Endpoint Description Use Content Type Affiliation Endpoint Location
Other Identifiers
Issuer State Number
Other PROVIDER # 00A853280
Primary Taxonomy Selected Taxonomy State License Number
Yes 207R00000X - Internal Medicine CA A85378