Provider Demographics
NPI:1003156126
Name:DJERBAKA, JOHN (PT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:DJERBAKA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17251 17TH ST
Mailing Address - Street 2:STE. A&B
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-1970
Mailing Address - Country:US
Mailing Address - Phone:714-832-2273
Mailing Address - Fax:714-832-2272
Practice Address - Street 1:17251 17TH ST
Practice Address - Street 2:STE. A&B
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1970
Practice Address - Country:US
Practice Address - Phone:714-832-2273
Practice Address - Fax:714-832-2272
Is Sole Proprietor?:No
Enumeration Date:2013-02-26
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 22204225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist