Provider Demographics
NPI:1487612073
Name:MCCONNELLOGUE, JOHN (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:MCCONNELLOGUE
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 1:7301 MEDICAL CENTER DR STE 404
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91307-1930
Mailing Address - Country:US
Mailing Address - Phone:818-347-3239
Mailing Address - Fax:818-348-0444
Practice Address - Street 1:7301 MEDICAL CENTER DR STE 404
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91307-1930
Practice Address - Country:US
Practice Address - Phone:818-347-3239
Practice Address - Fax:818-348-0444
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG32529207P00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G325290Medicaid
CAWG32529AMedicare ID - Type Unspecified
F15056Medicare UPIN