Healthcare Provider Details

I. General information

NPI: 1447606322
Provider Name (Legal Business Name): JEFFREY TYLER WHITSON IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34101 FARENHOLT AVE BUILDING 14
SAN DIEGO CA
92134-7000
US

IV. Provider business mailing address

720 CAMINO DE LA REINA APT 114
SAN DIEGO CA
92108-3236
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-0000
  • Fax:
Mailing address:
  • Phone: 912-326-1579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: