Provider Demographics
NPI:1093138042
Name:WORLAND, SHANE (IDC)
Entity Type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:WORLAND
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1558 SAN JAVIER CT # 3
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-2534
Mailing Address - Country:US
Mailing Address - Phone:757-375-7598
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CTR
Practice Address - Street 2:34800 BOB WILSON DRIVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:757-375-7598
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman