Active NPI
John Louis Vicelja, D.D.S.
- General Practice Dentistry
- Redondo Beach, CA
National Provider Identifier
1083875694
On this page
Key facts
NPPES NPI Registry- Primary specialty
- General Practice Dentistry
- License
- 33396
- Practice address
- 1711 Via El Prado
303
Redondo Beach, CA 90277-5714 - Phone
- (310) 792-4833
- Fax
- (310) 792-4837
- NPI assigned
- Jun 17, 2008
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| General Practice Dentistry | 1223G0001X | 33396 | CA | Primary |
Addresses
Primary practice location
1711 Via El Prado
303
Redondo Beach, CA 90277-5714
Mailing address
1711 Via El Prado
303
Redondo Beach, CA 90277-5714
Phone (310) 792-4833
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
- Eligible to order & refer
- Part B services: Yes
- Medical equipment: Yes
- Home health: Yes
- Power mobility devices: No
- Hospice: Yes
- Opted out of Medicare
- Yes, effective Jun 17, 2015 through Jun 17, 2027
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 33396 | CA | MD | Physical Therapist |
Interoperability endpoints
- https://api.platform.athenahealth.com/7116/brand/1/csg/1/fhir/r4
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1213660800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1213660800000",
"number": "1083875694",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "1711 VIA EL PRADO",
"address_2": "303",
"city": "REDONDO BEACH",
"state": "CA",
"postal_code": "902775714",
"telephone_number": "310-792-4833",
"fax_number": "310-792-4837"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "1711 VIA EL PRADO",
"address_2": "303",
"city": "REDONDO BEACH",
"state": "CA",
"postal_code": "902775714",
"telephone_number": "310-792-4833",
"fax_number": "310-792-4837"
}
],
"practiceLocations": [],
"basic": {
"last_name": "VICELJA",
"first_name": "JOHN",
"middle_name": "LOUIS",
"name_prefix": "Mr.",
"credential": "D.D.S.",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2008-06-17",
"last_updated": "2008-06-17",
"status": "A"
},
"taxonomies": [
{
"code": "1223G0001X",
"taxonomy_group": "",
"desc": "Dentist, General Practice",
"state": "CA",
"license": "33396",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Redondo Beach, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jun 17, 2008; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring; Opt Out Affidavits.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.