Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | PT 22204 | CA |
NPI | 1003156126 |
---|---|
Provider Name | John Djerbaka |
First Address | Tustin, CA 92780-1970 |
Second Address | Tustin, CA 92780-1970 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/02/2013 |
Last Update Date | 30/11/2016 |