MEDICARE: STEPHON PEYTON FROST SFIDC

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

General Provider Information

NPI Number	:	1255943635
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHON PEYTON FROST SFIDC

Provider Business Mailing Address
First Line	:	PO BOX 280046
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32228-0046
Country	:	US
Telephone Number	:	904-270-3806
Fax Number	:

Provider Business Practice Location Address
First Line	:	2654 MENDONCA DR
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-4263
Country	:	US
Telephone Number	:	518-961-6153
Fax Number	:

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

Provider Enumeration Date	:	08/18/2020
Last Update Date	:	12/29/2020

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