Provider Demographics
NPI:1831125277
Name:JOHN R PEDROTTY JR MD A PROF CORP
Entity Type:Organization
Organization Name:JOHN R PEDROTTY JR MD A PROF CORP
Other - Org Name:JOHN R PEDROTTY JR MD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:RICHARD
Authorized Official - Last Name:PEDROTTY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:619-435-7100
Mailing Address - Street 1:1222 FIRST ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CORONADO
Mailing Address - State:CA
Mailing Address - Zip Code:92118-1414
Mailing Address - Country:US
Mailing Address - Phone:619-435-7100
Mailing Address - Fax:619-435-7115
Practice Address - Street 1:1222 FIRST ST
Practice Address - Street 2:SUITE 1
Practice Address - City:CORONADO
Practice Address - State:CA
Practice Address - Zip Code:92118-1414
Practice Address - Country:US
Practice Address - Phone:619-435-7100
Practice Address - Fax:619-435-7115
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-25
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G802340Medicaid
G32901Medicare UPIN
CA00G802340Medicaid