Basic Information
Provider Information | |||||||||
NPI: | 1700059698 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | REISBORD-ROJANY | ||||||||
FirstName: | JODIE | ||||||||
MiddleName: | DEANNA | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REISBORD | ||||||||
OtherFirstName: | JODIE | ||||||||
OtherMiddleName: | DEANNA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | M.D. | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 3291 LOMA VISTA RD | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930033099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056526656 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3291 LOMA VISTA RD | ||||||||
Address2: |   | ||||||||
City: | VENTURA | ||||||||
State: | CA | ||||||||
PostalCode: | 930033099 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056526656 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2008 | ||||||||
LastUpdateDate: | 06/30/2009 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A71549 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | A71549 | 01 | CA | STATE MEDICAL LICENSE | OTHER |