Provider Demographics
NPI:1134473820
Name:GALLEGUILLOS, JASON LEE (IDC)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:LEE
Last Name:GALLEGUILLOS
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 1:2917 C ST
Mailing Address - Street 2:UNIT 187
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-2296
Mailing Address - Country:US
Mailing Address - Phone:760-208-8939
Mailing Address - Fax:
Practice Address - Street 1:2917 C ST
Practice Address - Street 2:UNIT 187
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-2296
Practice Address - Country:US
Practice Address - Phone:760-208-8939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-01
Last Update Date:2012-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman