Provider Demographics
NPI:1235296864
Name:HISERODT, JOHN CHATFIELD (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHATFIELD
Last Name:HISERODT
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 1:7707 GARDEN GROVE BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92841-4207
Mailing Address - Country:US
Mailing Address - Phone:714-902-1762
Mailing Address - Fax:657-400-9073
Practice Address - Street 1:7707 GARDEN GROVE BLVD
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-4207
Practice Address - Country:US
Practice Address - Phone:714-902-1762
Practice Address - Fax:657-400-9073
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77372207ZC0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G773720Medicaid
CAG77372OtherCALIFORNIA MEDICAL LICENS
CAG77372OtherCALIFORNIA MEDICAL LICENS
CAG77372Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER