Healthcare Provider Details

I. General information

NPI: 1447551569
Provider Name (Legal Business Name): JULIO OVANDO JR. CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 11/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3174 DENVER ST
SAN DIEGO CA
92117-6141
US

IV. Provider business mailing address

3174 DENVER ST
SAN DIEGO CA
92117-6141
US

V. Phone/Fax

Practice location:
  • Phone: 530-351-1952
  • Fax:
Mailing address:
  • Phone: 530-351-1952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number830061
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: