Provider Demographics
NPI:1720282239
Name:MASSIMINO, JOHN HENRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:HENRY
Last Name:MASSIMINO
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 1:30262 CROWN VALLEY PKWY
Mailing Address - Street 2:SUITE B-400
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-2364
Mailing Address - Country:US
Mailing Address - Phone:949-413-7315
Mailing Address - Fax:
Practice Address - Street 1:30262 CROWN VALLEY PKWY
Practice Address - Street 2:SUITE B-400
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-2364
Practice Address - Country:US
Practice Address - Phone:949-413-7315
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-11
Last Update Date:2008-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA-36137103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical