Provider Demographics
NPI:1346280229
Name:MERILLAT, JOHN CHARLES (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:CHARLES
Last Name:MERILLAT
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 1:1540 FLORIDA AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4430
Mailing Address - Country:US
Mailing Address - Phone:209-577-5557
Mailing Address - Fax:209-579-7246
Practice Address - Street 1:1540 FLORIDA AVE STE 100
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4430
Practice Address - Country:US
Practice Address - Phone:209-577-5557
Practice Address - Fax:209-579-7246
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG67546207RC0001X, 207RI0011X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ76734ZMedicaid
CAZZZ76734ZMedicare ID - Type Unspecified
B69631Medicare UPIN