Provider Demographics
NPI:1487967907
Name:ARDENT MEDICAL GROUP
Entity type:Organization
Organization Name:ARDENT MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:UYEN
Authorized Official - Last Name:NGUYEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-728-2494
Mailing Address - Street 1:3805 HEDGE LN
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-7754
Mailing Address - Country:US
Mailing Address - Phone:630-728-2494
Mailing Address - Fax:805-389-4884
Practice Address - Street 1:3801 LAS POSAS RD
Practice Address - Street 2:SUITE #211
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-1427
Practice Address - Country:US
Practice Address - Phone:805-389-0099
Practice Address - Fax:805-389-4884
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-26
Last Update Date:2010-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90331207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI43932Medicare PIN