Provider Demographics
NPI:1144340662
Name:ENCEPHALOGIC MEDICAL GROUP, INC.
Entity type:Organization
Organization Name:ENCEPHALOGIC MEDICAL GROUP, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT - MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:SUTTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-278-4148
Mailing Address - Street 1:1701 SOLAR DR
Mailing Address - Street 2:SUITE 140
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93030-0134
Mailing Address - Country:US
Mailing Address - Phone:805-278-4148
Mailing Address - Fax:805-278-4634
Practice Address - Street 1:1701 SOLAR DR
Practice Address - Street 2:SUITE 140
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-0134
Practice Address - Country:US
Practice Address - Phone:805-278-4148
Practice Address - Fax:805-278-4634
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2013-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103G00000X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurologyGroup - Multi-Specialty
No103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15396Medicare ID - Type Unspecified