Provider Demographics
NPI:1427583947
Name:MCTAVISH, PATRICK (IDC)
Entity Type:Individual
Prefix:
First Name:PATRICK
Middle Name:
Last Name:MCTAVISH
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 1:3781 ATLAS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-4353
Mailing Address - Country:US
Mailing Address - Phone:805-479-8828
Mailing Address - Fax:
Practice Address - Street 1:3781 ATLAS ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92111-4353
Practice Address - Country:US
Practice Address - Phone:805-479-8828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-21
Last Update Date:2017-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD86008671710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman