Healthcare Provider Details

I. General information

NPI: 1194358747
Provider Name (Legal Business Name): ALEXANDER JOSEPH VIDUNAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2020
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL HOSPITAL CAMP PENDLETON MERCY CIRCLE
CAMP PENDLETON CA
92055-5191
US

IV. Provider business mailing address

NAVAL HOSPITAL CAMP PENDLETON BOX 555191 MERCY CIRCLE
CAMP PENDLETON CA
92055-5191
US

V. Phone/Fax

Practice location:
  • Phone: 570-490-2400
  • Fax:
Mailing address:
  • Phone: 760-719-4747
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License NumberDS042748
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: