Provider Demographics
NPI:1528163136
Name:FOX, JOHN LOGAN (MPT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:LOGAN
Last Name:FOX
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24630 WASHINGTON AVE
Mailing Address - Street 2:STE. 200
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-6131
Mailing Address - Country:US
Mailing Address - Phone:951-696-9353
Mailing Address - Fax:951-973-7216
Practice Address - Street 1:920 LOHMAN LN
Practice Address - Street 2:
Practice Address - City:S PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91030-2906
Practice Address - Country:US
Practice Address - Phone:323-254-6000
Practice Address - Fax:323-254-6003
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26110225100000X, 2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT261100OtherBLUE SHIELD OF CALIFORNIA
CA0PT261100Medicare PIN
CA0PT261100OtherBLUE SHIELD OF CALIFORNIA