Provider Demographics
NPI:1114123791
Name:CORDOVA, LUIS F (IDC)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:F
Last Name:CORDOVA
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 1:1ST MEDICAL BATTALION 1ST MARINE LOGISTIC GROUP
Mailing Address - Street 2:CAMP PENDLETON
Mailing Address - City:FPO
Mailing Address - State:US
Mailing Address - Zip Code:92055
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1ST MEDICAL BATTALION 1ST MARINE LOGISTIC GROUP
Practice Address - Street 2:CAMP PENDLETON
Practice Address - City:FPO
Practice Address - State:US
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-4041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman