Provider Demographics
NPI:1831353366
Name:MADRAZO TORRES, JUAN F
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:F
Last Name:MADRAZO TORRES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:591 TELEGRAPH CANYON RD # 616
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-6436
Mailing Address - Country:US
Mailing Address - Phone:619-730-9603
Mailing Address - Fax:
Practice Address - Street 1:224 LANDIS AVE
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2609
Practice Address - Country:US
Practice Address - Phone:619-730-9603
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2022-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29443103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831353366Medicaid