Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208G00000X | Cardiothoracic Vascular Surgeon | A104894 | CA |
N | 208G00000X | Cardiothoracic Vascular Surgeon | PENDING | CA |
NPI | 1043472871 |
---|---|
Provider Name | Dr. John B Degraft-Johnson |
First Address | Modesto, CA 95350-4438 |
Second Address | Modesto, CA 95350 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 02/07/2008 |
Last Update Date | 14/06/2018 |