Healthcare Provider Details

I. General information

NPI: 1154388601
Provider Name (Legal Business Name): JOHANNES M. NEUENDORF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 11/06/2020
Certification Date: 11/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10710 N TORREY PINES RD
LA JOLLA CA
92037-1035
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-554-8638
  • Fax: 858-554-9283
Mailing address:
  • Phone: 858-554-8638
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberL9392
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number20A9506
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A9506
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberL9392
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: