Provider Demographics
NPI:1629084678
Name:JAVIDAN, PATRICK (DC)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:
Last Name:JAVIDAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9524 KEARNY VILLA RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92126-4582
Mailing Address - Country:US
Mailing Address - Phone:858-693-3196
Mailing Address - Fax:858-695-9201
Practice Address - Street 1:9524 KEARNY VILLA RD
Practice Address - Street 2:SUITE 111
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92126-4582
Practice Address - Country:US
Practice Address - Phone:858-693-3196
Practice Address - Fax:858-695-9201
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2013-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27094111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0270940OtherBLUE SHIELD PROVIDER #
CADC0270940Medicare UPIN
CAW16450Medicare ID - Type Unspecified