Provider Demographics
NPI:1124016837
Name:UPHOLD, JOHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:UPHOLD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 4419
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91365-4419
Mailing Address - Country:US
Mailing Address - Phone:818-340-9988
Mailing Address - Fax:818-587-2493
Practice Address - Street 1:309 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-4308
Practice Address - Country:US
Practice Address - Phone:323-726-1222
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC36283207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C362830Medicaid
CAWC36283AMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
CAA36218Medicare UPIN