Provider Demographics
NPI:1528382231
Name:MALDONADO, JOHN PHILLIP
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILLIP
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 23RD ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94804
Mailing Address - Country:US
Mailing Address - Phone:510-229-5000
Mailing Address - Fax:510-235-3112
Practice Address - Street 1:820 23RD ST
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804
Practice Address - Country:US
Practice Address - Phone:510-229-5000
Practice Address - Fax:510-235-3112
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2010-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA070004101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)