Basic Information
| Provider Information | |||||||||
| NPI: | 1346337821 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARRUTH | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | H | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24422 AVENIDA DE LA CARLOTA STE 300 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926533628 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495992434 | ||||||||
| FaxNumber: | 9495992430 | ||||||||
| Practice Location | |||||||||
| Address1: | 30210 RANCHO VIEJO RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494937337 | ||||||||
| FaxNumber: | 9493731300 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 05/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | G35292 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | GROO8160 | 05 | CA | MEDICAID |