Provider Demographics
NPI:1033175922
Name:DEBANTO, JOHN ROBERT (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:DEBANTO
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 1:9802 STOCKDALE HWY
Mailing Address - Street 2:STE 102
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-3653
Mailing Address - Country:US
Mailing Address - Phone:678-897-3726
Mailing Address - Fax:
Practice Address - Street 1:1412 1/2 CALUMET AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90026-5494
Practice Address - Country:US
Practice Address - Phone:678-897-3726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG86400207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10331756922Medicaid
CA10331756922Medicaid