Basic Information
Provider Information | |||||||||
NPI: | 1194796268 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRONTERA | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 742616 | ||||||||
Address2: |   | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303742616 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702198420 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1315 JESSE JEWELL PARKWAY | ||||||||
Address2: |   | ||||||||
City: | GAINESVILLE | ||||||||
State: | GA | ||||||||
PostalCode: | 30501 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7702196520 | ||||||||
FaxNumber: | 7702196521 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/27/2006 | ||||||||
LastUpdateDate: | 01/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 01/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | MD070263L | PA | Y |   | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
ID | Type | State | Issuer | Description | 0018031450003 | 05 | PA |   | MEDICAID | 000830541B | 05 | GA |   | MEDICAID | 443534 | 01 | PA | HIGHMARK BS | OTHER | 820123 | 01 | PA | FIRST PRIORITY HEALTH | OTHER | 20048652 | 01 | PA | AMERIHEALTH MERCY | OTHER | 58052 | 01 | PA | GEISINGER | OTHER | 0018031450005 | 05 | PA |   | MEDICAID | 50057449 | 01 | PA | KEYSTONE CAPITAL BC | OTHER | 5686065 | 01 |   | FIRST HEALTH | OTHER |