Healthcare Provider Details

I. General information

NPI: 1396308698
Provider Name (Legal Business Name): JOHN ZACHARIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

522 E GRANGER AVE
MODESTO CA
95350-4545
US

IV. Provider business mailing address

500 N 9TH ST
MODESTO CA
95350-5814
US

V. Phone/Fax

Practice location:
  • Phone: 209-558-4610
  • Fax:
Mailing address:
  • Phone: 209-558-4610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-MQSNDC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: