Healthcare Provider Details

I. General information

NPI: 1477537942
Provider Name (Legal Business Name): JUAN CARLOS PEQUENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2005
Last Update Date: 12/21/2020
Certification Date: 12/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 BAILEY AVE STE 2
NEEDLES CA
92363-3105
US

IV. Provider business mailing address

303 E VANDERBILT WAY
SAN BERNARDINO CA
92415-0026
US

V. Phone/Fax

Practice location:
  • Phone: 760-326-9313
  • Fax: 760-326-2864
Mailing address:
  • Phone: 909-388-0806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberAZ28640
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code2084P0802X
TaxonomyAddiction Psychiatry Physician
License NumberA61571
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: