Provider Demographics
NPI:1528003399
Name:NACKLEY, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:NACKLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:27212 CALAROGA AVE
Mailing Address - Street 2:
Mailing Address - City:HAYWARD
Mailing Address - State:CA
Mailing Address - Zip Code:94545-4339
Mailing Address - Country:US
Mailing Address - Phone:510-785-5000
Mailing Address - Fax:510-784-2502
Practice Address - Street 1:20126 STANTON AVE
Practice Address - Street 2:STE 201
Practice Address - City:CASTRO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94546-5271
Practice Address - Country:US
Practice Address - Phone:510-581-2559
Practice Address - Fax:510-581-5396
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC33919208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA35428Medicare UPIN