Healthcare Provider Details

I. General information

NPI: 1033175922
Provider Name (Legal Business Name): JOHN ROBERT DEBANTO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2006
Last Update Date: 04/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1412 1/2 CALUMET AVE
LOS ANGELES CA
90026-5494
US

IV. Provider business mailing address

9802 STOCKDALE HWY STE 102
BAKERSFIELD CA
93311-3653
US

V. Phone/Fax

Practice location:
  • Phone: 678-897-3726
  • Fax:
Mailing address:
  • Phone: 678-897-3726
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License NumberG86400
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: