Healthcare Provider Details

I. General information

NPI: 1740244664
Provider Name (Legal Business Name): ANGELO MEDINA CALIVOSO MSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 01/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NORFOLK NAVAL BASE - CSU EAST 581 A ST BLDG SP-312 ROOM 115
NORFOLK VA
23511
US

IV. Provider business mailing address

36283 VERAMONTE AVE
MURRIETA CA
92562-6505
US

V. Phone/Fax

Practice location:
  • Phone: 757-443-5760
  • Fax:
Mailing address:
  • Phone: 619-578-4009
  • 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: