Provider Demographics
NPI:1437267911
Name:NEPOMUCENO, MD, INC.
Entity Type:Organization
Organization Name:NEPOMUCENO, MD, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:NEPOMUCENO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-244-1003
Mailing Address - Street 1:PO BOX 994463
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-4463
Mailing Address - Country:US
Mailing Address - Phone:530-244-1003
Mailing Address - Fax:530-242-6026
Practice Address - Street 1:15660 MIDDLETOWN PARK DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-9794
Practice Address - Country:US
Practice Address - Phone:530-244-1003
Practice Address - Fax:530-242-6027
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-26
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094270Medicaid
CAGR0094270Medicaid
CAZZZ28412ZMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
CAG16658Medicare UPIN