Healthcare Provider Details

I. General information

NPI: 1366677445
Provider Name (Legal Business Name): NAVAL MEDICAL CENTER SAN DIEGO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/19/2009
Last Update Date: 05/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 CUSHING RD
SAN DIEGO CA
92106-6173
US

IV. Provider business mailing address

2051 CUSHING RD
SAN DIEGO CA
92106-6173
US

V. Phone/Fax

Practice location:
  • Phone: 619-524-0113
  • Fax: 619-524-6318
Mailing address:
  • Phone: 619-524-0113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code286500000X
TaxonomyMilitary Hospital
License Number1710I1002X
License Number StateCA

VIII. Authorized Official

Name: MR. THOMAS BALCOM
Title or Position: SENIOR MEDICAL OFFICER
Credential:
Phone: 619-524-0113