Provider Demographics
NPI:1417197591
Name:NAVAL MEDICAL CENTER SAN DIEGO
Entity Type:Organization
Organization Name:NAVAL MEDICAL CENTER SAN DIEGO
Other - Org Name:US NAVY
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:N
Authorized Official - Last Name:LIGHTCAP
Authorized Official - Suffix:
Authorized Official - Credentials:IDC
Authorized Official - Phone:619-437-0777
Mailing Address - Street 1:2446 TRIDENT WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92155-5494
Mailing Address - Country:US
Mailing Address - Phone:619-437-0777
Mailing Address - Fax:619-437-5248
Practice Address - Street 1:2446 TRIDENT WAY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5494
Practice Address - Country:US
Practice Address - Phone:619-437-0777
Practice Address - Fax:619-437-5248
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:US NAVY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-03-02
Last Update Date:2009-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center