Healthcare Provider Details

I. General information

NPI: 1063498749
Provider Name (Legal Business Name): JUAN RODERICK BALZA PAGSOLINGAN D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/15/2005
Last Update Date: 11/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 CANAL ST
KING CITY CA
93930-3432
US

IV. Provider business mailing address

210 CANAL ST
KING CITY CA
93930-3432
US

V. Phone/Fax

Practice location:
  • Phone: 831-385-5471
  • Fax: 831-385-5940
Mailing address:
  • Phone: 831-385-5471
  • Fax: 831-385-5940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE4169
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE4169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: