Provider Demographics
NPI:1861492647
Name:COBO, JUAN CARLOS (MD)
Entity Type:Individual
Prefix:DR
First Name:JUAN CARLOS
Middle Name:
Last Name:COBO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24310 MOULTON PKWY
Mailing Address - Street 2:STE O #563
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92637-3306
Mailing Address - Country:US
Mailing Address - Phone:949-297-3612
Mailing Address - Fax:949-495-8258
Practice Address - Street 1:24310 MOULTON PKWY
Practice Address - Street 2:STE O #563
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92637-3306
Practice Address - Country:US
Practice Address - Phone:949-297-3612
Practice Address - Fax:949-495-8258
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-22
Last Update Date:2014-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG42070208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA48801Medicare UPIN
CAWG42070AMedicare ID - Type Unspecified