Healthcare Provider Details

I. General information

NPI: 1811274152
Provider Name (Legal Business Name): JUAN FERNANDO ESTRADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2011
Last Update Date: 06/18/2025
Certification Date: 06/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5275 MARKET ST SUITE # E
SAN DIEGO CA
92114-2212
US

IV. Provider business mailing address

5275 MARKET ST SUITE # E
SAN DIEGO CA
92114-2212
US

V. Phone/Fax

Practice location:
  • Phone: 619-857-4775
  • Fax:
Mailing address:
  • Phone: 619-857-4775
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-LQGYTK
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: