Provider Demographics
NPI:1669408522
Name:MARDONES, JOHN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:MARDONES
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:PO BOX 2993
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92202-2993
Mailing Address - Country:US
Mailing Address - Phone:800-819-2392
Mailing Address - Fax:
Practice Address - Street 1:47111 MONROE ST
Practice Address - Street 2:PO DRAWER LLLL
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-6739
Practice Address - Country:US
Practice Address - Phone:760-347-6191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41581207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
A41581OtherRIVERSIDE CO EMS
CA00A415810Medicaid
A41581OtherBLUE CROSS
00A415810OtherBLUE SHIELD
930065998Medicare ID - Type UnspecifiedRAILROAD MEDICARE
00A415810Medicare ID - Type Unspecified
CA00A415810Medicaid
A41581OtherBLUE CROSS