Provider Demographics
NPI:1629158449
Name:PALENCIA, FERNANDO JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:FERNANDO
Middle Name:
Last Name:PALENCIA
Suffix:JR
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 1:1433 NORMANDY DR
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-3904
Mailing Address - Country:US
Mailing Address - Phone:323-401-9926
Mailing Address - Fax:
Practice Address - Street 1:3455 STURTEVANT ST
Practice Address - Street 2:SUITE 1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5069
Practice Address - Country:US
Practice Address - Phone:619-556-6671
Practice Address - Fax:619-556-0888
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman