Provider Demographics
NPI:1639355381
Name:JOHN W. SCIVALLY, D.P.M INC
Entity type:Organization
Organization Name:JOHN W. SCIVALLY, D.P.M INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/ PHYSICIAN
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:SCIVALLY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:925-937-2860
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-11
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4319213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E43190Medicaid
CA000E43190Medicaid
CAE83908Medicare UPIN
4744190001Medicare NSC