Healthcare Provider Details

I. General information

NPI: 1073691705
Provider Name (Legal Business Name): BIJU JOHN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MULECREEK STATE PRISON, HIGHWAY 104
IONE CA
95640-9099
US

IV. Provider business mailing address

PO BOX 409099 MULECREEK STATE PRISON, ATTN:PERSONNEL DEPT
IONE CA
95640-9099
US

V. Phone/Fax

Practice location:
  • Phone: 209-274-4911
  • Fax:
Mailing address:
  • Phone: 209-274-4911
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA79801
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: