Provider Demographics
NPI:1477673770
Name:NEPOMUCENO, JOHN ELAZEGUI (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELAZEGUI
Last Name:NEPOMUCENO
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:PO BOX 992337
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96099-2337
Mailing Address - Country:US
Mailing Address - Phone:702-453-3799
Mailing Address - Fax:530-243-1612
Practice Address - Street 1:1520 COLLYER DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-9535
Practice Address - Country:US
Practice Address - Phone:702-453-3799
Practice Address - Fax:530-243-1612
Is Sole Proprietor?:No
Enumeration Date:2007-03-30
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC50728207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0094270Medicaid
CAGR0094270Medicaid
CAZZZ28412ZMedicare ID - Type UnspecifiedMEDICARE