Provider Demographics
NPI:1407846157
Name:DEZA, JUAN (MD)
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:DEZA
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 1:7910 FROST STREET
Mailing Address - Street 2:SUITE 245
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123
Mailing Address - Country:US
Mailing Address - Phone:858-650-5037
Mailing Address - Fax:858-650-5039
Practice Address - Street 1:7910 FROST STREET
Practice Address - Street 2:SUITE 245
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123
Practice Address - Country:US
Practice Address - Phone:858-650-5037
Practice Address - Fax:858-650-5039
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA45058207RC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A450580Medicaid
CAB11567Medicare UPIN
CA00A450580Medicaid