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General NPI Number Information
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NPI Number | 1588006878
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Entity Type | Individual
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Provider Name | JON RYAN O'HARE IDC
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Gender | Male
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Dates
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Enumeration Date | 07/26/2013
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Last Update Date | 05/15/2025
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Provider Practice Location Address
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Address Line | SPECIAL BOAT TEAM TWELVE 3402 TARAWA ROAD
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City | SAN DIEGO
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State | CA
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Zip | 92155-9227
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Country | US
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Telephone | 619-437-5540
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Fax |
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Provider Business Mailing Address
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Address Line | 7749 CALLE ANDAR
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City | CARLSBAD
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State | CA
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Zip | 92009-9227
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Country | US
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Telephone | 760-585-6160
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171000000X
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Taxonomy Name | Military Health Care Provider
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License Number |
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License Number State |
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