Provider Demographics
NPI:1689769051
Name:DISAIA, JOHN PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PHILIP
Last Name:DISAIA
Suffix:
Gender:M
Credentials:MD
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Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3553 CAMINO MIRA COSTA
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-3512
Mailing Address - Country:US
Mailing Address - Phone:949-369-5932
Mailing Address - Fax:949-369-5088
Practice Address - Street 1:3553 CAMINO MIRA COSTA
Practice Address - Street 2:SUITE A
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-3512
Practice Address - Country:US
Practice Address - Phone:949-369-5932
Practice Address - Fax:949-369-5088
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2009-09-25
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Provider Licenses
StateLicense IDTaxonomies
CAG072451208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG76560Medicare UPIN