Healthcare Provider Details

I. General information

NPI: 1366797706
Provider Name (Legal Business Name): ELIZABETH J DEMAGNO, M.D., APC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2012
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 E VIRGINIA WAY SUITE A
BARSTOW CA
92311-3955
US

IV. Provider business mailing address

705 E VIRGINIA WAY SUITE A
BARSTOW CA
92311-3955
US

V. Phone/Fax

Practice location:
  • Phone: 760-256-2181
  • Fax:
Mailing address:
  • Phone: 760-256-2181
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA47902
License Number StateCA

VIII. Authorized Official

Name: ELIZABETH J DEMAGNO
Title or Position: PRESIDENT
Credential: MD
Phone: 760-256-2181