Healthcare Provider Details

I. General information

NPI: 1346280229
Provider Name (Legal Business Name): JOHN CHARLES MERILLAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 FLORIDA AVE STE 100
MODESTO CA
95350-4430
US

IV. Provider business mailing address

1540 FLORIDA AVE STE 100
MODESTO CA
95350-4430
US

V. Phone/Fax

Practice location:
  • Phone: 209-577-5557
  • Fax: 209-579-7246
Mailing address:
  • Phone: 209-577-5557
  • Fax: 209-579-7246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberG67546
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License NumberG67546
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberG67546
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: