Healthcare Provider Details

I. General information

NPI: 1528292471
Provider Name (Legal Business Name): JOHN CHAMP NEELY II M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2009
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HIGHLAND DR
MANY LA
71449-3718
US

IV. Provider business mailing address

338 VIA VERA CRUZ STE 100
SAN MARCOS CA
92078-2645
US

V. Phone/Fax

Practice location:
  • Phone: 318-256-5691
  • Fax:
Mailing address:
  • Phone: 904-643-4353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD2022-1046
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number51688
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.205104
License Number StateLA
# 4
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberA149450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: