Basic Information
| Provider Information | |||||||||
| NPI: | 1003987082 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TREVINO | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | M. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 62106 | ||||||||
| Address2: | |||||||||
| City: | SANTA BARBARA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 931602106 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056811761 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1017 E OCEAN AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | LOMPOC | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934367000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056811761 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 10/17/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | G30668 | CA | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 00G306680 | 05 | CA | MEDICAID |