MEDICARE: DAMON MARCUS DERTINA MD

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	207L00000X	Anesthesiology Physician	A98936	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	00A989360	OTHER	CA	BLUE SHIELD OF CA

General Provider Information

NPI Number	:	1588877963
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAMON MARCUS DERTINA MD

Provider Business Mailing Address
First Line	:	34800 BOB WILSON DR STE 409
Second Line	:	DEPT OF ANESTHESIOLOGY, NAVAL MEDICAL CENTER SAN DIEGO
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-1409
Country	:	US
Telephone Number	:	619-453-6922
Fax Number	:

Provider Business Practice Location Address
First Line	:	34800 BOB WILSON DR STE 409
Second Line	:	DEPT OF ANESTHESIOLOGY, NAVAL MEDICAL CENTER SAN DIEGO
City	:	SAN DIEGO
State	:	CA
Zip	:	92134-1409
Country	:	US
Telephone Number	:	619-453-6922
Fax Number	:

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

Provider Enumeration Date	:	05/08/2007
Last Update Date	:	06/07/2023

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