Provider Demographics
NPI:1487667101
Name:NESSON, JOHN WILLARD (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:WILLARD
Last Name:NESSON
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 1:333 N SANTA ANITA AVE
Mailing Address - Street 2:SUITE 9
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91006-2863
Mailing Address - Country:US
Mailing Address - Phone:626-445-0004
Mailing Address - Fax:626-445-0302
Practice Address - Street 1:150 PIONEER LN
Practice Address - Street 2:
Practice Address - City:BISHOP
Practice Address - State:CA
Practice Address - Zip Code:93514-2556
Practice Address - Country:US
Practice Address - Phone:760-873-2171
Practice Address - Fax:626-445-0302
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA221202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A221201Medicaid
CAZZZ04744ZOtherBLUE SHIELD
CAA22120OtherBLUE CROSS
CAA22120OtherBLUE CROSS
CAZZZ22246ZMedicare ID - Type Unspecified