Provider Demographics
NPI:1659772044
Name:ESTARES, JOHN V
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:V
Last Name:ESTARES
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 1:3075 PARTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32526-3607
Mailing Address - Country:US
Mailing Address - Phone:850-384-7656
Mailing Address - Fax:
Practice Address - Street 1:3075 PARTRIDGE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32526-3607
Practice Address - Country:US
Practice Address - Phone:850-384-7656
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL6906454171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL003088100Medicaid