Healthcare Provider Details

I. General information

NPI: 1417126764
Provider Name (Legal Business Name): JUAN FERNANDO LIZARRAGA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 05/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

895 W. VALLEY BLVD.
COLTON CA
92324-4809
US

IV. Provider business mailing address

8915 W, VALLEY BLVD
COLTON CA
92324-4809
US

V. Phone/Fax

Practice location:
  • Phone: 562-654-6855
  • Fax: 562-654-6856
Mailing address:
  • Phone: 909-824-3389
  • Fax: 909-824-3389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberA49181
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: