Provider Demographics
NPI:1225079502
Name:PHILLIPS, JOHN PATRICK (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
Last Name:PHILLIPS
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 1:2100 POWELL ST STE 900
Mailing Address - Street 2:
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:1303 E HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-3309
Practice Address - Country:US
Practice Address - Phone:559-450-3281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2019-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG46208207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46208OtherBC OF CA
CA00G462080Medicaid
00G462080OtherBS OF CA
CR0087Medicare PIN
00G462080Medicare PIN
G46208OtherBC OF CA
ZZZ34627ZMedicare PIN
00G462080OtherBS OF CA