Healthcare Provider Details

I. General information

NPI: 1477673770
Provider Name (Legal Business Name): JOHN ELAZEGUI NEPOMUCENO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2007
Last Update Date: 06/20/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1520 COLLYER DR
REDDING CA
96003-9535
US

IV. Provider business mailing address

PO BOX 992337
REDDING CA
96099-2337
US

V. Phone/Fax

Practice location:
  • Phone: 702-453-3799
  • Fax: 530-243-1612
Mailing address:
  • Phone: 702-453-3799
  • Fax: 530-243-1612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC50728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: