Provider Demographics
NPI:1306811625
Name:DEL JUNCO, TIRSO JR (MD)
Entity type:Individual
Prefix:
First Name:TIRSO
Middle Name:
Last Name:DEL JUNCO
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14860 ROSCOE BLVD
Mailing Address - Street 2:200
Mailing Address - City:PANORAMA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91402-4665
Mailing Address - Country:US
Mailing Address - Phone:818-997-5000
Mailing Address - Fax:818-997-5005
Practice Address - Street 1:14860 ROSCOE BLVD
Practice Address - Street 2:200
Practice Address - City:PANORAMA CITY
Practice Address - State:CA
Practice Address - Zip Code:91402-4665
Practice Address - Country:US
Practice Address - Phone:818-997-5000
Practice Address - Fax:818-997-5005
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-21
Last Update Date:2016-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41067208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A410670Medicaid
CA00A410670Medicaid
1306811625Medicare UPIN