Basic Information
| Provider Information | |||||||||
| NPI: | 1073662912 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CONTI | ||||||||
| FirstName: | JON | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30210 RANCHO VIEJO RD STE A | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494931383 | ||||||||
| FaxNumber: | 9494931418 | ||||||||
| Practice Location | |||||||||
| Address1: | 30210 RANCHO VIEJO RD STE A | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494931383 | ||||||||
| FaxNumber: | 9494931418 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2007 | ||||||||
| LastUpdateDate: | 12/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A71854 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | A71854 | 01 | CA | MEDICAL LICENSE | OTHER | BC7216030 | 01 | CA | DEA LICENSE | OTHER |