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General NPI Number Information
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NPI Number | 1740244664
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Entity Type | Individual
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Provider Name | ANGELO MEDINA CALIVOSO MSO
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Gender | Male
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Dates
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Enumeration Date | 04/17/2006
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Last Update Date | 01/22/2019
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Provider Practice Location Address
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Address Line | NORFOLK NAVAL BASE - CSU EAST 581 A ST BLDG SP-312 ROOM 115
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City | NORFOLK
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State | VA
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Zip | 23511
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Country | US
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Telephone | 757-443-5760
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Fax |
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Provider Business Mailing Address
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Address Line | 36283 VERAMONTE AVE
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City | MURRIETA
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State | CA
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Zip | 92562-6505
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Country | US
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Telephone | 619-578-4009
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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 | 1710I1003X
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Taxonomy Name | Independent Duty Medical Technicians
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License Number |
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License Number State |
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