Basic Information
Provider Information | |||||||||
NPI: | 1487763579 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | VENTURINI | ||||||||
FirstName: | ALFRED | ||||||||
MiddleName: | MAXWELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 737 W CHILDS AVE | ||||||||
Address2: |   | ||||||||
City: | MERCED | ||||||||
State: | CA | ||||||||
PostalCode: | 953416805 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2093831848 | ||||||||
FaxNumber: | 2093831296 | ||||||||
Practice Location | |||||||||
Address1: | 1510 FLORIDA AVE | ||||||||
Address2: |   | ||||||||
City: | MODESTO | ||||||||
State: | CA | ||||||||
PostalCode: | 953504437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2095497090 | ||||||||
FaxNumber: | 2095497099 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/30/2006 | ||||||||
LastUpdateDate: | 01/25/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | A022460 | CA | Y |   | Other Service Providers | Specialist |   |
ID Information
ID | Type | State | Issuer | Description | 00A22460 | 05 | CA |   | MEDICAID |