Provider Demographics
NPI:1578124194
Name:ALLEN, DAVID M (IDC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:ALLEN
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 1:2004 BURROUGHS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-6619
Mailing Address - Country:US
Mailing Address - Phone:210-818-7207
Mailing Address - Fax:
Practice Address - Street 1:1ST MLG
Practice Address - Street 2:BLDG 150121
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:210-818-7207
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-25
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider