Provider Demographics
NPI:1003827825
Name:MACLEAN, JON WALTER (DO)
Entity type:Individual
Prefix:DR
First Name:JON
Middle Name:WALTER
Last Name:MACLEAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 S MILLER ST
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-6959
Mailing Address - Country:US
Mailing Address - Phone:805-922-3573
Mailing Address - Fax:805-922-7972
Practice Address - Street 1:1420 S MILLER ST
Practice Address - Street 2:SUITE J
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-6959
Practice Address - Country:US
Practice Address - Phone:805-922-3573
Practice Address - Fax:805-922-7972
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6626208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00AX66260Medicaid
H16769Medicare UPIN