Basic Information
Provider Information | |||||||||
NPI: | 1801019534 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BEHRENDTSEN | ||||||||
FirstName: | OLE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 315 CAMINO DEL REMEDIO | ||||||||
Address2: |   | ||||||||
City: | SANTA BARBARA | ||||||||
State: | CA | ||||||||
PostalCode: | 931101332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056815450 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 315 CAMINO DEL REMEDIO | ||||||||
Address2: |   | ||||||||
City: | SANTA BARBARA | ||||||||
State: | CA | ||||||||
PostalCode: | 931101332 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8056815450 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/11/2007 | ||||||||
LastUpdateDate: | 08/04/2011 | ||||||||
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 | 207R00000X | R6903 | IA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 37227 | IA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 2084P0800X | 37227 | IA | N |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | A111247 | CA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
ID | Type | State | Issuer | Description | 56589 | 01 | IA | WELLMARK BCBS | OTHER | P00411059 | 01 | IA | RAILROAD MEDICARE | OTHER |