Provider Demographics
NPI:1528292471
Name:NEELY, JOHN CHAMP II (MD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:CHAMP
Last Name:NEELY
Suffix:II
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 1:338 VIA VERA CRUZ STE 100
Mailing Address - Street 2:
Mailing Address - City:SAN MARCOS
Mailing Address - State:CA
Mailing Address - Zip Code:92078-2645
Mailing Address - Country:US
Mailing Address - Phone:904-643-4353
Mailing Address - Fax:
Practice Address - Street 1:240 HIGHLAND DR
Practice Address - Street 2:
Practice Address - City:MANY
Practice Address - State:LA
Practice Address - Zip Code:71449-3718
Practice Address - Country:US
Practice Address - Phone:318-256-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2022-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2022-1046207N00000X
TN51688207P00000X
LAMD.205104207R00000X
CAA149450207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR2157621Medicaid
LA4R150DT25Medicare PIN