Provider Demographics
NPI:1578552279
Name:JUAN C. DEZA, INC
Entity Type:Organization
Organization Name:JUAN C. DEZA, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JUAN
Authorized Official - Middle Name:
Authorized Official - Last Name:DEZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-439-6581
Mailing Address - Street 1:3156 VISTA WAY
Mailing Address - Street 2:SUITE 405
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-3622
Mailing Address - Country:US
Mailing Address - Phone:760-439-6581
Mailing Address - Fax:760-439-6585
Practice Address - Street 1:4002 VISTA WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92056-4506
Practice Address - Country:US
Practice Address - Phone:760-439-6581
Practice Address - Fax:760-439-6585
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JUAN C. DEZA, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-10-17
Last Update Date:2008-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA45058OtherLICENSE NUMBER
CA00A450580Medicaid
CA00A450580Medicaid