Healthcare Provider Details

I. General information

NPI: 1083768295
Provider Name (Legal Business Name): JOHN J ESTRADA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2007
Last Update Date: 03/30/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1245 WILSHIRE BLVD SUITE 817
LOS ANGELES CA
90017-4808
US

IV. Provider business mailing address

1245 WILSHIRE BLVD SUITE 817
LOS ANGELES CA
90017-4808
US

V. Phone/Fax

Practice location:
  • Phone: 213-482-1395
  • Fax: 213-482-1398
Mailing address:
  • Phone: 213-482-1395
  • Fax: 213-482-1398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberC27180
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC27180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: