Healthcare Provider Details

I. General information

NPI: 1396873493
Provider Name (Legal Business Name): JOHN DAVID HUSTED M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2007
Last Update Date: 01/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3660 PARK SIERRA DR STE 105
RIVERSIDE CA
92505-3081
US

IV. Provider business mailing address

PO BOX 2828
CORONA CA
92878-2828
US

V. Phone/Fax

Practice location:
  • Phone: 951-278-8870
  • Fax: 951-278-8913
Mailing address:
  • Phone: 951-278-8870
  • Fax: 951-278-8913

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberG68530
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: