Provider Demographics
NPI:1619907359
Name:DEPOLO, JOHN LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:LAWRENCE
Last Name:DEPOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1801 E MARCH LANE
Mailing Address - Street 2:SUITE C300
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-948-1425
Mailing Address - Fax:209-464-0193
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:SUITE C300
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-948-1425
Practice Address - Fax:209-464-0193
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA22978207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A229780Medicaid
CA00A229780Medicaid
CA00A229780Medicare PIN