Provider Demographics
NPI:1912195199
Name:CALDERON, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:CALDERON
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 1:14642 RUNNYMEDE ST
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-1911
Mailing Address - Country:US
Mailing Address - Phone:818-989-1996
Mailing Address - Fax:818-989-8056
Practice Address - Street 1:14332 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91401-1944
Practice Address - Country:US
Practice Address - Phone:818-989-1996
Practice Address - Fax:818-989-8056
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)