Provider Demographics
NPI:1043358104
Name:PHILLIPP, JUANA CONSTANTINA (MD)
Entity Type:Individual
Prefix:DR
First Name:JUANA
Middle Name:CONSTANTINA
Last Name:PHILLIPP
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 W ROUTE 66
Mailing Address - Street 2:SUITE #220
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6249
Mailing Address - Country:US
Mailing Address - Phone:626-914-5803
Mailing Address - Fax:
Practice Address - Street 1:130 W ROUTE 66
Practice Address - Street 2:SUITE #220
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6249
Practice Address - Country:US
Practice Address - Phone:626-914-5803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA33955207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOOA339550Medicaid
CAA84544Medicare UPIN
CAOOA339550Medicaid