Provider Demographics
NPI:1073691705
Name:JOHN, BIJU (MD)
Entity Type:Individual
Prefix:
First Name:BIJU
Middle Name:
Last Name:JOHN
Suffix:
Gender:M
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:PO BOX 409099
Mailing Address - Street 2:MULECREEK STATE PRISON, ATTN:PERSONNEL DEPT
Mailing Address - City:IONE
Mailing Address - State:CA
Mailing Address - Zip Code:95640-9099
Mailing Address - Country:US
Mailing Address - Phone:209-274-4911
Mailing Address - Fax:
Practice Address - Street 1:MULECREEK STATE PRISON, HIGHWAY 104
Practice Address - Street 2:
Practice Address - City:IONE
Practice Address - State:CA
Practice Address - Zip Code:95640-9099
Practice Address - Country:US
Practice Address - Phone:209-274-4911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2009-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA798012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A798010Medicaid
G74013Medicare UPIN
00A798010Medicare ID - Type Unspecified