Healthcare Provider Details

I. General information

NPI: 1093193427
Provider Name (Legal Business Name): JUAN CARLOS VERA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

IV. Provider business mailing address

5555 GROSSMONT CENTER DR
LA MESA CA
91942-3019
US

V. Phone/Fax

Practice location:
  • Phone: 619-740-4008
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberA172415
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberA172415
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: