=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417126764
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUAN FERNANDO LIZARRAGA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2008
-----------------------------------------------------
Last Update Date | 05/15/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 895 W. VALLEY BLVD.
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 562-654-6855
-----------------------------------------------------
Fax | 562-654-6856
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8915 W, VALLEY BLVD
-----------------------------------------------------
City | COLTON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92324-4809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-824-3389
-----------------------------------------------------
Fax | 909-824-3389
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | A49181
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------