MEDICARE: MR. ROBERT DAVID GERARDI IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1710I1002X	OTHER	CA	INDEPENDENT DUTY CORPSMAN

General Provider Information

NPI Number	:	1003840653
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ROBERT DAVID GERARDI IDC

Provider Business Mailing Address
First Line	:	2841 RENDOVA ROAD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155
Country	:	US
Telephone Number	:	619-437-2329
Fax Number	:	619-437-2700

Provider Business Practice Location Address
First Line	:	2841 RENDOVA ROAD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92155
Country	:	US
Telephone Number	:	619-437-2329
Fax Number	:	619-437-2700

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	07/08/2007

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