Healthcare Provider Details

I. General information

NPI: 1023400256
Provider Name (Legal Business Name): BRANCH MEDICAL CLINIC MCAS MIRAMAR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/25/2015
Last Update Date: 11/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BAUER RD BLDG 2496
SAN DIEGO CA
92145-0001
US

IV. Provider business mailing address

BAUER RD BLDG 2496
SAN DIEGO CA
92145-0001
US

V. Phone/Fax

Practice location:
  • Phone: 858-577-4656
  • Fax:
Mailing address:
  • Phone: 858-577-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1100X
TaxonomyMilitary/U.S. Coast Guard Outpatient Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM M CONDON
Title or Position: BUMED UBO
Credential:
Phone: 240-401-3643