Healthcare Provider Details

I. General information

NPI: 1548588270
Provider Name (Legal Business Name): JOHN L ETCHEVERRY DPM INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2010
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BAHAMAS DR 200
BAKERSFIELD CA
93309-0745
US

IV. Provider business mailing address

6815 NOBLE AVE
VAN NUYS CA
91405-3796
US

V. Phone/Fax

Practice location:
  • Phone: 661-328-5565
  • Fax: 818-997-7826
Mailing address:
  • Phone: 818-901-6600
  • Fax: 818-997-7826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberE4099
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4099
License Number StateCA

VIII. Authorized Official

Name: JOHN L ETCHEVERRY
Title or Position: PRESIDENT/OWNER
Credential: M.D.
Phone: 818-901-6600