Provider Demographics
NPI:1164724928
Name:CHURCH, JOHN (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CHURCH
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 368
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-0030
Mailing Address - Country:US
Mailing Address - Phone:800-451-7811
Mailing Address - Fax:888-777-2067
Practice Address - Street 1:2340 POWELL ST
Practice Address - Street 2:#402
Practice Address - City:EMERYVILLE
Practice Address - State:CA
Practice Address - Zip Code:94608-1738
Practice Address - Country:US
Practice Address - Phone:800-451-7811
Practice Address - Fax:888-777-2067
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-30
Last Update Date:2010-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA605472084P0800X
NY2028052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry