Healthcare Provider Details

I. General information

NPI: 1871908236
Provider Name (Legal Business Name): MARK JOHN DEBANO JR. O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/24/2014
Last Update Date: 10/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

PSC 810 BOX 193
FPO AE
09589-0002
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6400
  • Fax:
Mailing address:
  • Phone: 757-458-2998
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number3353-35
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3353-35
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: