Provider Demographics
NPI:1508164278
Name:QUEJADO, PETER SORIBEN II (IDC)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:SORIBEN
Last Name:QUEJADO
Suffix:II
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:SWMI
Mailing Address - Street 2:34101 FARENHOLT AVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-0001
Mailing Address - Country:US
Mailing Address - Phone:619-518-9139
Mailing Address - Fax:
Practice Address - Street 1:SWMI
Practice Address - Street 2:34101 FARENHOLT AVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-518-9139
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman