Provider Demographics
NPI:1326397597
Name:VANN, RICARDO JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:RICARDO
Middle Name:
Last Name:VANN
Suffix:JR
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 1:10179 HOOPER ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3510
Mailing Address - Country:US
Mailing Address - Phone:619-840-7572
Mailing Address - Fax:
Practice Address - Street 1:HM2 VANN, RICARDO
Practice Address - Street 2:MED
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96629
Practice Address - Country:US
Practice Address - Phone:619-545-3616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-04
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman