Provider Demographics
NPI:1144254764
Name:KEARNEY, JOHN P (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:KEARNEY
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 1:355 E 21ST ST STE C
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-4851
Mailing Address - Country:US
Mailing Address - Phone:909-883-6811
Mailing Address - Fax:909-883-2494
Practice Address - Street 1:355 E 21ST ST STE C
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4851
Practice Address - Country:US
Practice Address - Phone:909-883-6811
Practice Address - Fax:909-883-2494
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2018-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG26058208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G260580Medicaid
CA00G260580Medicaid
CA00G260580Medicare ID - Type Unspecified