Provider Demographics
NPI:1407029069
Name:NYLUND, JOHN KEITH (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:KEITH
Last Name:NYLUND
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:14650 AVIATION BLVD
Mailing Address - Street 2:SUITE 235
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-6668
Mailing Address - Country:US
Mailing Address - Phone:310-643-9333
Mailing Address - Fax:310-643-9337
Practice Address - Street 1:14650 AVIATION BLVD
Practice Address - Street 2:SUITE 235
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-6656
Practice Address - Country:US
Practice Address - Phone:310-643-9333
Practice Address - Fax:310-643-9337
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO34111207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWWH7CBOtherPASSWORD FOR PALMETTO
CACO34111OtherSTATE MEDICAL LISCECE
CAW9243OtherPPTAN #