Basic Information
| Provider Information | |||||||||
| NPI: | 1265469878 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ENGSTROM | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WALTER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1635 DIVISADERO STREET | ||||||||
| Address2: | SUITE 625, BOX 1821 | ||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941430001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154764029 | ||||||||
| FaxNumber: | 4154764150 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 PARNASSUS AVE | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941432202 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4153532273 | ||||||||
| FaxNumber: | 4153532898 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 10/13/2017 | ||||||||
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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 | 207R00000X | G52739 | CA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 2084N0600X | G52739 | CA | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Clinical Neurophysiology | 2084N0400X | G52739 | CA | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 00G527390 | 05 | CA | MEDICAID |