Provider Demographics
NPI:1174517791
Name:O'CONNOR, JOHN P (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:O'CONNOR
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22521 AVENIDA EMPRESA STE 116
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2046
Mailing Address - Country:US
Mailing Address - Phone:949-766-8535
Mailing Address - Fax:949-766-8540
Practice Address - Street 1:22521 AVENIDA EMPRESA STE 116
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2046
Practice Address - Country:US
Practice Address - Phone:949-766-8535
Practice Address - Fax:949-766-8540
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT10045225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW15276OtherMEDICARE GROUP
CAW14553OtherMEDICARE GROUP
CAR36040Medicare UPIN
CAWPT11045BMedicare UPIN
CAWPT10045AMedicare ID - Type UnspecifiedPERFORMING PROVIDER ID #