Healthcare Provider Details

I. General information

NPI: 1184850760
Provider Name (Legal Business Name): JOSE VICTOR NAZARIO IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2009
Last Update Date: 11/10/2021
Certification Date: 10/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 MDG 340 MAGNOLIA CIRCLE
TYNDALL AFB FL
32403-8888
US

IV. Provider business mailing address

628 ED MOYE RD
LA GRANGE NC
28551-8888
US

V. Phone/Fax

Practice location:
  • Phone: 240-216-3247
  • Fax:
Mailing address:
  • Phone: 240-216-3247
  • 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: