Provider Demographics
NPI:1215591920
Name:VENTURA COUNTY PODIATRIC MEDICAL GROUP INC
Entity type:Organization
Organization Name:VENTURA COUNTY PODIATRIC MEDICAL GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:SCOT
Authorized Official - Middle Name:
Authorized Official - Last Name:ROBERG
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:805-485-6708
Mailing Address - Street 1:451 W GONZALES RD STE 260
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-0729
Mailing Address - Country:US
Mailing Address - Phone:805-485-6708
Mailing Address - Fax:805-278-2299
Practice Address - Street 1:711 N A STREET
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-4309
Practice Address - Country:US
Practice Address - Phone:805-983-0222
Practice Address - Fax:805-604-9872
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-29
Last Update Date:2020-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE3640OtherCA STATE LICENSE