Provider Demographics
NPI:1871526145
Name:DERMATOLOGY MEDICAL GROUP OF OXNARD AND CAMARILLO
Entity type:Organization
Organization Name:DERMATOLOGY MEDICAL GROUP OF OXNARD AND CAMARILLO
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:E
Authorized Official - Last Name:LAU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-983-0343
Mailing Address - Street 1:2811 N VENTURA RD
Mailing Address - Street 2:
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-2213
Mailing Address - Country:US
Mailing Address - Phone:805-983-0343
Mailing Address - Fax:805-983-3285
Practice Address - Street 1:2811 N VENTURA RD
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-2213
Practice Address - Country:US
Practice Address - Phone:805-983-0343
Practice Address - Fax:805-983-3285
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-09
Last Update Date:2011-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CP2197OtherRAILROAD MEDICARE
W1120Medicare PIN