Provider Demographics
NPI:1083768295
Name:ESTRADA, JOHN J (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:J
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:1245 WILSHIRE BLVD
Mailing Address - Street 2:SUITE 817
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90017-4808
Mailing Address - Country:US
Mailing Address - Phone:213-482-1395
Mailing Address - Fax:213-482-1398
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:SUITE 817
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4808
Practice Address - Country:US
Practice Address - Phone:213-482-1395
Practice Address - Fax:213-482-1398
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAC27180207N00000X, 261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A33299Medicare UPIN
A332992Medicare UPIN
W4449Medicare ID - Type Unspecified