Provider Demographics
NPI:1598736449
Name:GARRITSON, MICHAEL TAD (IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:TAD
Last Name:GARRITSON
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 1:5151 ROBINWOOD RD
Mailing Address - Street 2:APT. 8
Mailing Address - City:BONITA
Mailing Address - State:CA
Mailing Address - Zip Code:91902
Mailing Address - Country:US
Mailing Address - Phone:619-992-6997
Mailing Address - Fax:
Practice Address - Street 1:2446 TRIDENT WAY
Practice Address - Street 2:MEDICAL CLINIC
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5494
Practice Address - Country:US
Practice Address - Phone:619-437-0777
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman