Provider Demographics
NPI:1114091816
Name:EMISON, JOHN WESLEY (MD, DDS)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WESLEY
Last Name:EMISON
Suffix:
Gender:M
Credentials:MD, DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15780 LOS GATOS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2508
Mailing Address - Country:US
Mailing Address - Phone:408-358-5000
Mailing Address - Fax:408-358-7936
Practice Address - Street 1:15780 LOS GATOS BLVD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2508
Practice Address - Country:US
Practice Address - Phone:408-358-5000
Practice Address - Fax:408-358-7936
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA47705204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA878OtherANESTHESIA
CABE1791753OtherDEA
D87080Medicare UPIN
00A477050Medicare ID - Type Unspecified