Basic Information
| Provider Information | |||||||||
| NPI: | 1912077314 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHANNEL ISLANDS PLASTIC & RECONSTRUCTIVE SURGERY MEDICAL GROUP, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11999 SAN VICENTE BLVD | ||||||||
| Address2: | #440 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900495131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104715852 | ||||||||
| FaxNumber: | 3104713958 | ||||||||
| Practice Location | |||||||||
| Address1: | 1801 SOLAR DR | ||||||||
| Address2: | #150 | ||||||||
| City: | OXNARD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930308234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8059831999 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | STARR | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 8059831999 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | A39823 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Otolaryngology | 208200000X | A39823 | CA | X | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Plastic Surgery |
No ID Information.