Healthcare Provider Details

I. General information

NPI: 1679925648
Provider Name (Legal Business Name): JAKE CORMAN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 03/18/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

US NAVAL HOSPITAL VIA CONTRADA BOSCARIELLO
FPO AE
81030-9998
US

IV. Provider business mailing address

1145 STURGIS RD
TWENTYNINE PALMS CA
92278
US

V. Phone/Fax

Practice location:
  • Phone: 81-811-6000
  • Fax:
Mailing address:
  • Phone: 760-830-2117
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberDR.0067731
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: