Healthcare Provider Details

I. General information

NPI: 1679500219
Provider Name (Legal Business Name): JOHN ROBERT DEQUARDO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

IV. Provider business mailing address

1600 W 24TH ST
PUEBLO CO
81003-1411
US

V. Phone/Fax

Practice location:
  • Phone: 719-546-4816
  • Fax: 719-546-4874
Mailing address:
  • Phone: 719-546-4816
  • Fax: 719-546-4874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number38515
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: