Provider Demographics
NPI:1992861629
Name:PEDROTTY, JOHN RICHARD JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:PEDROTTY
Suffix:JR
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 1:1222 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
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG080234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G32901Medicare UPIN
W19782Medicare ID - Type Unspecified