Provider Demographics
NPI:1134125578
Name:COMPAGNO, JOHN
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:COMPAGNO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:COMPAGNO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:712 ALFRED NOBEL DR
Mailing Address - Street 2:
Mailing Address - City:HERCULES
Mailing Address - State:CA
Mailing Address - Zip Code:94547-1805
Mailing Address - Country:US
Mailing Address - Phone:510-662-5200
Mailing Address - Fax:
Practice Address - Street 1:712 ALFRED NOBEL DR
Practice Address - Street 2:
Practice Address - City:HERCULES
Practice Address - State:CA
Practice Address - Zip Code:94547-1805
Practice Address - Country:US
Practice Address - Phone:510-662-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG38126174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G381261Medicaid
CA00G381261Medicare ID - Type UnspecifiedMEDCARE PROVIDER NUMBER