Healthcare Provider Details

I. General information

NPI: 1851587075
Provider Name (Legal Business Name): TIMOTHY WAYNE SEFA IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2007
Last Update Date: 09/20/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35000 GUADALCANAL AVE
SAN DIEGO CA
92140-5599
US

IV. Provider business mailing address

10264 WADDELL CIR
SAN DIEGO CA
92124-2934
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-8307
  • Fax:
Mailing address:
  • Phone: 858-571-7402
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: