Healthcare Provider Details

I. General information

NPI: 1619907359
Provider Name (Legal Business Name): JOHN LAWRENCE DEPOLO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 E MARCH LN SUITE C300
STOCKTON CA
95210-6629
US

IV. Provider business mailing address

1801 E MARCH LANE SUITE C300
STOCKTON CA
95210-6629
US

V. Phone/Fax

Practice location:
  • Phone: 209-948-1425
  • Fax: 209-464-0193
Mailing address:
  • Phone: 209-948-1425
  • Fax: 209-464-0193

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberA22978
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: