Provider Demographics
NPI:1841399235
Name:ELIAS, JOHN FERNANDO N (MD)
Entity Type:Individual
Prefix:
First Name:JOHN FERNANDO
Middle Name:N
Last Name:ELIAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:J. FERNANDO
Other - Middle Name:
Other - Last Name:ELIAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1401 SPANOS CT
Mailing Address - Street 2:STE 121
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95355-2810
Mailing Address - Country:US
Mailing Address - Phone:209-525-3135
Mailing Address - Fax:209-525-3193
Practice Address - Street 1:1401 SPANOS CT
Practice Address - Street 2:STE 121
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-2810
Practice Address - Country:US
Practice Address - Phone:209-525-3135
Practice Address - Fax:209-525-3193
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA039877208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5939222Medicare UPIN