Provider Demographics
NPI:1063565604
Name:BRENT STREET FAMILY PRACTICE
Entity type:Organization
Organization Name:BRENT STREET FAMILY PRACTICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:F
Authorized Official - Last Name:DODGE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-641-2000
Mailing Address - Street 1:168 N BRENT ST
Mailing Address - Street 2:STE 502
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2817
Mailing Address - Country:US
Mailing Address - Phone:805-641-2000
Mailing Address - Fax:805-653-1644
Practice Address - Street 1:168 N BRENT ST
Practice Address - Street 2:STE 502
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2817
Practice Address - Country:US
Practice Address - Phone:805-641-2000
Practice Address - Fax:805-653-1644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG40594207Q00000X
CAG26650207Q00000X
CAG46052207Q00000X
CAG43925207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G266500Medicaid
CA00G405940Medicaid
CA00G460520Medicaid
CA00G439250Medicaid
CAWG46052CMedicare ID - Type Unspecified
CA00G460520Medicaid
CAA49499Medicare UPIN
CAWG26650CMedicare ID - Type Unspecified
CAA43056Medicare UPIN
CAWG40594CMedicare ID - Type Unspecified
CAA89824Medicare UPIN
CA00G405940Medicaid