| Vista Del Mar Medical Group, Inc | |
|
1200 W Gonzales Rd Suite 300 Oxnard CA 93036-3072 | |
| (805) 983-0691 | |
| (805) 981-1643 |
| Full Name | Vista Del Mar Medical Group, Inc |
|---|---|
| Speciality | Internal Medicine |
| Location | 1200 W Gonzales Rd, Oxnard, California |
| Authorized Official Name and Position | Richard K Westerdoll (EXECUTIVE DIRECTOR) |
| Authorized Official Contact | 8059830691 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Vista Del Mar Medical Group, Inc 1200 W Gonzales Rd Suite 300 Oxnard CA 93036-3072 Ph: (805) 983-0691 | Vista Del Mar Medical Group, Inc 1200 W Gonzales Rd Suite 300 Oxnard CA 93036-3072 Ph: (805) 983-0691 |
| NPI Number | 1942239694 |
|---|---|
| Provider Enumeration Date | 07/02/2006 |
| Last Update Date | 11/12/2021 |
| Medicare PECOS PAC ID | 1951357888 |
|---|---|
| Medicare Enrollment ID | O20050323001422 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1942239694 | NPI | - | NPPES |
| 110039977 | Other | CA | MEDICARE RAILROAD |
| ZZZ75566Z | Medicaid | CA | |
| ZZZ34679Z | Other | CA | BLUE CROSS |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207R00000X | Internal Medicine | FNP4189 (California) | Secondary |
| 207RN0300X | Internal Medicine - Nephrology | FNP4189 (California) | Primary |
| Provider Name | Koosha Mortazavi |
|---|---|
| Provider Type | Practitioner - Nephrology |
| Provider Identifiers | NPI Number: 1215966999 PECOS PAC ID: 3274545496 Enrollment ID: I20060706000272 |
| Provider Name | Rajendra P Niraula |
|---|---|
| Provider Type | Practitioner - Nephrology |
| Provider Identifiers | NPI Number: 1922201003 PECOS PAC ID: 7214020510 Enrollment ID: I20091102000158 |
| Provider Name | Steven G Ledesma |
|---|---|
| Provider Type | Practitioner - Nephrology |
| Provider Identifiers | NPI Number: 1386718799 PECOS PAC ID: 9436199718 Enrollment ID: I20110105000632 |
| Provider Name | Tane Liu |
|---|---|
| Provider Type | Practitioner - Nephrology |
| Provider Identifiers | NPI Number: 1588738991 PECOS PAC ID: 4880749464 Enrollment ID: I20110620000348 |
| Provider Name | Ali P Dana |
|---|---|
| Provider Type | Practitioner - Nephrology |
| Provider Identifiers | NPI Number: 1669561536 PECOS PAC ID: 4981898848 Enrollment ID: I20130906000841 |
| Provider Name | Chonlada Chivangkul |
|---|---|
| Provider Type | Practitioner - Nephrology |
| Provider Identifiers | NPI Number: 1184063570 PECOS PAC ID: 4183974256 Enrollment ID: I20180911002440 |
| Provider Name | Juliana Resuello Labrador |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1629759659 PECOS PAC ID: 2668812397 Enrollment ID: I20240429002783 |
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