Healthcare Provider Details

I. General information

NPI: 1811144546
Provider Name (Legal Business Name): NELSON JOSE MEJIA IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 08/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33000 NIXIE WAY BLDG.#50, STE.#245
SAN DIEGO CA
92147-5101
US

IV. Provider business mailing address

1150 CANARY CT
SAN MARCOS CA
92078-1302
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-5137
  • Fax:
Mailing address:
  • Phone: 611-984-3644
  • 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: