Healthcare Provider Details

I. General information

NPI: 1225086861
Provider Name (Legal Business Name): JOHN LEVI COON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 12/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 JACKSON ST SUITE 201
RIVERSIDE CA
92503
US

IV. Provider business mailing address

3975 JACKSON ST SUITE 201
RIVERSIDE CA
92503
US

V. Phone/Fax

Practice location:
  • Phone: 951-687-9400
  • Fax: 951-687-9401
Mailing address:
  • Phone: 951-687-9400
  • Fax: 951-687-9401

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG31115
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: