Healthcare Provider Details

I. General information

NPI: 1548270333
Provider Name (Legal Business Name): JOHN DEKUTOSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 09/06/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4150 CLEMENT ST GB17, (11C3)
SAN FRANCISCO CA
94121-1545
US

IV. Provider business mailing address

4150 CLEMENT ST GB17, (11C3)
SAN FRANCISCO CA
94121-1545
US

V. Phone/Fax

Practice location:
  • Phone: 415-750-2122
  • Fax: 415-750-2249
Mailing address:
  • Phone: 415-750-2122
  • Fax: 415-750-2249

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberG035124
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: