Provider Demographics
NPI:1275523375
Name:AFFELDT, JOHN C (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:C
Last Name:AFFELDT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1427
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-0836
Mailing Address - Country:US
Mailing Address - Phone:909-825-3425
Mailing Address - Fax:909-825-6991
Practice Address - Street 1:11370 ANDERSON ST STE 1800
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-3450
Practice Address - Country:US
Practice Address - Phone:909-558-2154
Practice Address - Fax:909-558-2180
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG38490207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G384901OtherBLUE CROSS
CA00G384900Medicaid
CAA91997Medicare UPIN
CA00G384900Medicaid