Provider Demographics
NPI:1861770513
Name:OCEANSIDE MEDICAL GROUP, A MEDICAL CORPORATION
Entity type:Organization
Organization Name:OCEANSIDE MEDICAL GROUP, A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GADSON
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-993-4103
Mailing Address - Street 1:701 SANTA MONICA BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90401-2623
Mailing Address - Country:US
Mailing Address - Phone:310-993-4103
Mailing Address - Fax:805-494-8385
Practice Address - Street 1:701 SANTA MONICA BLVD
Practice Address - Street 2:SUITE 230
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90401-2623
Practice Address - Country:US
Practice Address - Phone:310-993-4103
Practice Address - Fax:805-494-8385
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-29
Last Update Date:2011-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFNP41555OtherFNP