Basic Information
| Provider Information | |||||||||
| NPI: | 1043255797 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILIP | ||||||||
| FirstName: | STEPHANUS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3291 LOMA VISTA RD | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930033099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056526075 | ||||||||
| FaxNumber: | 8056526286 | ||||||||
| Practice Location | |||||||||
| Address1: | 3291 LOMA VISTA RD | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930033099 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056526075 | ||||||||
| FaxNumber: | 8056526286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2006 | ||||||||
| LastUpdateDate: | 07/14/2009 | ||||||||
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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 | 207R00000X | A87363 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | A87363 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist | 208000000X | A87363 | CA | N | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 00A873630 | 01 | CA | MCAL PROVIDER NUMBER | OTHER | WA87363D | 01 | CA | MEDICARE PTAN | OTHER |