Provider Demographics
NPI:1467686543
Name:ISSITT, MARY (IDMT)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:
Last Name:ISSITT
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:CRUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5344 ANTHONY CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1581
Mailing Address - Country:US
Mailing Address - Phone:501-615-5633
Mailing Address - Fax:
Practice Address - Street 1:DAVID GRANT MEDICAL CENTER
Practice Address - Street 2:101 BODIN CIRCLE
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-0001
Practice Address - Country:US
Practice Address - Phone:707-816-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-05
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians