Provider Demographics
NPI:1154388601
Name:NEUENDORF, JOHANNES M (DO)
Entity type:Individual
Prefix:
First Name:JOHANNES
Middle Name:M
Last Name:NEUENDORF
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 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-554-8638
Mailing Address - Fax:
Practice Address - Street 1:10710 N TORREY PINES RD
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1035
Practice Address - Country:US
Practice Address - Phone:858-554-8638
Practice Address - Fax:858-554-9283
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A9506207Q00000X, 207P00000X
TXL9392207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H73895Medicare UPIN
CABC651ZMedicare PIN