Provider Demographics
NPI:1366438574
Name:LIQUETE, JOHNNY A (MD)
Entity type:Individual
Prefix:
First Name:JOHNNY
Middle Name:A
Last Name:LIQUETE
Suffix:
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:PO BOX 8838
Mailing Address - Street 2:
Mailing Address - City:MORENO VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92552-8838
Mailing Address - Country:US
Mailing Address - Phone:951-697-1150
Mailing Address - Fax:951-697-1189
Practice Address - Street 1:14114 BUSINESS CENTER DR
Practice Address - Street 2:SUITE D
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92553-9113
Practice Address - Country:US
Practice Address - Phone:951-697-1150
Practice Address - Fax:951-697-1189
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA49014207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A490141Medicaid
CA00A490141Medicaid
CA00A490140Medicare ID - Type Unspecified