Healthcare Provider Details

I. General information

NPI: 1134188048
Provider Name (Legal Business Name): MATTHEW NORMAN CASE SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR
SAN DIEGO CA
92134-0001
US

IV. Provider business mailing address

MEDICAL READINESS DIVISION SAN 3985 CUMMINGS RD
SAN DIEGO CA
92136-0001
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-5136
  • Fax:
Mailing address:
  • Phone: 619-508-6622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number1164814587
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: