Healthcare Provider Details

I. General information

NPI: 1104845775
Provider Name (Legal Business Name): JOHN P. FARACI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 10/21/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11370 ANDERSON ST # 3200
LOMA LINDA CA
92354
US

IV. Provider business mailing address

11370 ANDERSON ST # 3200
LOMA LINDA CA
92354-3450
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-2395
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberME46902
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number0438327
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License NumberG162574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: