Provider Demographics
NPI:1871028878
Name:ESTRADA, JUAN PABLO
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:PABLO
Last Name:ESTRADA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5141 VIRGINIA WAY STE 350
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2319
Mailing Address - Country:US
Mailing Address - Phone:630-519-6543
Mailing Address - Fax:
Practice Address - Street 1:1020 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2453
Practice Address - Country:US
Practice Address - Phone:931-954-1400
Practice Address - Fax:931-954-1550
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2023-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN65696207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program