MEDICARE: JUSTIN BENTON DAUGHERTY 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

General Provider Information

NPI Number	:	1992100911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN BENTON DAUGHERTY IDC

Provider Business Mailing Address
First Line	:	3124 SALMON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3605
Country	:	US
Telephone Number	:	402-699-7774
Fax Number	:

Provider Business Practice Location Address
First Line	:	3124 SALMON ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3605
Country	:	US
Telephone Number	:	402-699-7774
Fax Number	:

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

Provider Enumeration Date	:	11/03/2014
Last Update Date	:	11/03/2014

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