Healthcare Provider Details

I. General information

NPI: 1770805954
Provider Name (Legal Business Name): JAMES RYAN PITTS IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/16/2010
Last Update Date: 02/16/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 KNIGHT LANE BLDG. H NAVY MEDICINE SUPPORT COMMAND
JACKSONVILLE FL
32212-0140
US

IV. Provider business mailing address

11899 SPRUCE RUN DR APT A
SAN DIEGO CA
92131-4764
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-7285
  • Fax:
Mailing address:
  • Phone: 858-243-3031
  • 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: