Provider Demographics
NPI:1598027237
Name:VAITAUTOLU, EPAFARA JEFFREY
Entity Type:Individual
Prefix:
First Name:EPAFARA
Middle Name:JEFFREY
Last Name:VAITAUTOLU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS NIMITZ
Mailing Address - Street 2:CVN -68
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96620-2820
Mailing Address - Country:US
Mailing Address - Phone:360-434-1434
Mailing Address - Fax:
Practice Address - Street 1:30 WENCKER WAY APT A
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98312-1861
Practice Address - Country:US
Practice Address - Phone:360-434-1434
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-08
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman