Healthcare Provider Details

I. General information

NPI: 1851461610
Provider Name (Legal Business Name): PAUL D LOOMIS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL COASTAL WARFARE GROUP ONE NOLF IB 357140
SAN DIEGO CA
92135
US

IV. Provider business mailing address

2013 CLEARWATER PL
CHULA VISTA CA
91913-2461
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-9856
  • Fax:
Mailing address:
  • Phone:
  • 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: