Provider Demographics
NPI:1518951722
Name:SCIVALLY, JOHN W (DPM)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:W
Last Name:SCIVALLY
Suffix:
Gender:M
Credentials:DPM
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Other - First Name:
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Mailing Address - Street 1:2227 OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94595-1623
Mailing Address - Country:US
Mailing Address - Phone:925-937-2860
Mailing Address - Fax:925-937-5565
Practice Address - Street 1:2227 OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94595-1623
Practice Address - Country:US
Practice Address - Phone:925-937-2860
Practice Address - Fax:925-937-5565
Is Sole Proprietor?:No
Enumeration Date:2005-09-01
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4319213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43190Medicaid
CAE83908Medicare UPIN
CAZZZ25716ZMedicare ID - Type Unspecified