Basic Information
Provider Information | |||||||||
NPI: | 1629005475 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SIU | ||||||||
FirstName: | PATRICK | ||||||||
MiddleName: | K | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2705 LOMA VISTA RD | ||||||||
Address2: | SUITE 205 | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930031581 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056672801 | ||||||||
FaxNumber: | 8056672865 | ||||||||
Practice Location | |||||||||
Address1: | 422 ARNEILL RD STE B | ||||||||
Address2: |   | ||||||||
City: | CAMARILLO | ||||||||
State: | CA | ||||||||
PostalCode: | 930106434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8053834510 | ||||||||
FaxNumber: | 8053834511 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2006 | ||||||||
LastUpdateDate: | 07/09/2007 | ||||||||
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 | 207PE0004X | MD 4738 | HI | X |   | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207R00000X | G86731 | CA | X |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 01348502 | 05 | HI |   | MEDICAID | RHM08609F | 05 | CA |   | MEDICAID | D0014375 | 01 | HI | SHIELD/HMSA | OTHER | 050394 | 01 | CA | BLUE CROSS | OTHER | RHM18553H | 05 | CA |   | MEDICAID | RHM08608F | 05 | CA |   | MEDICAID | ZZT40394F | 05 | CA |   | MEDICAID |