Provider Demographics
NPI:1447305305
Name:CENTER FOR DIABETES, ENDOCRINOLOGY & NUTRITION
Entity type:Organization
Organization Name:CENTER FOR DIABETES, ENDOCRINOLOGY & NUTRITION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GULNAR
Authorized Official - Middle Name:
Authorized Official - Last Name:POORSATTAR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-482-5550
Mailing Address - Street 1:400 CAMARILLO RANCH RD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5901
Mailing Address - Country:US
Mailing Address - Phone:805-482-5550
Mailing Address - Fax:805-233-6367
Practice Address - Street 1:400 CAMARILLO RANCH RD
Practice Address - Street 2:#204
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-5901
Practice Address - Country:US
Practice Address - Phone:805-482-5550
Practice Address - Fax:805-233-6367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50561207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX-ID
CAWC50561AMedicare PIN
CA=========OtherTAX-ID
CAW16155Medicare PIN