Provider Demographics
NPI:1568512390
Name:PHILLIPP, JOHN TERENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:TERENCE
Last Name:PHILLIPP
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 1:130 W ROUTE 66
Mailing Address - Street 2:SUITE #220
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6249
Mailing Address - Country:US
Mailing Address - Phone:626-914-5803
Mailing Address - Fax:626-963-1569
Practice Address - Street 1:130 W ROUTE 66
Practice Address - Street 2:SUITE #220
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6249
Practice Address - Country:US
Practice Address - Phone:626-914-5803
Practice Address - Fax:626-963-1569
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2008-06-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG038878207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G388780Medicaid
CA00G388780Medicaid
CAWG38878AMedicare PIN