Provider Demographics
NPI:1356305866
Name:MAA, JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MAA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5 BON AIR ROAD #101
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94909
Mailing Address - Country:US
Mailing Address - Phone:415-924-2515
Mailing Address - Fax:415-924-2661
Practice Address - Street 1:250 BON AIR RD
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-1702
Practice Address - Country:US
Practice Address - Phone:415-924-2515
Practice Address - Fax:415-924-2661
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA55909208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A5590900Medicaid
CA0A5590900Medicare PIN
CAH64147Medicare UPIN