Healthcare Provider Details

I. General information

NPI: 1932450905
Provider Name (Legal Business Name): SHAWN DAVID MOCK C.P, D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2012
Last Update Date: 09/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 5TH AVE SUITE 100
SAN DIEGO CA
92103-5081
US

IV. Provider business mailing address

3585 5TH AVE SUITE 100
SAN DIEGO CA
92103-5081
US

V. Phone/Fax

Practice location:
  • Phone: 619-501-5383
  • Fax: 619-501-5390
Mailing address:
  • Phone: 619-501-5383
  • Fax: 619-501-5390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224P00000X
TaxonomyProsthetist
License NumberCP003901
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: