Provider Demographics
NPI:1902232804
Name:ZURITA, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:ZURITA
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 1:15055 SW ROYALTY PKWY
Mailing Address - Street 2:APT G26
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3915
Mailing Address - Country:US
Mailing Address - Phone:541-398-1164
Mailing Address - Fax:
Practice Address - Street 1:14619 SW TEAL BLVD
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97007
Practice Address - Country:US
Practice Address - Phone:541-398-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-24
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17757171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor