Healthcare Provider Details

I. General information

NPI: 1578124194
Provider Name (Legal Business Name): DAVID M ALLEN IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1ST MLG BLDG 150121
CAMP PENDLETON CA
92055
US

IV. Provider business mailing address

2004 BURROUGHS ST
SAN DIEGO CA
92111-6619
US

V. Phone/Fax

Practice location:
  • Phone: 210-818-7207
  • Fax:
Mailing address:
  • Phone: 210-818-7207
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: