Provider Demographics
NPI:1740441997
Name:PROBASCO, JOHN CALVIN (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CALVIN
Last Name:PROBASCO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 64227
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4227
Mailing Address - Country:US
Mailing Address - Phone:410-955-6626
Mailing Address - Fax:
Practice Address - Street 1:601 N CAROLINE ST
Practice Address - Street 2:JHOC 5
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0006
Practice Address - Country:US
Practice Address - Phone:410-955-8174
Practice Address - Fax:410-955-0672
Is Sole Proprietor?:No
Enumeration Date:2008-06-20
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD734322084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD056130400Medicaid
MD056130400Medicaid