Provider Demographics
NPI:1659159978
Name:DESPRADEL QUINTANA, WALTER JAVIER (MILITARY PROVIDER)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:JAVIER
Last Name:DESPRADEL QUINTANA
Suffix:
Gender:M
Credentials:MILITARY PROVIDER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:840 17TH ST APT 117
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6655
Mailing Address - Country:US
Mailing Address - Phone:619-642-7162
Mailing Address - Fax:
Practice Address - Street 1:840 17TH ST APT 117
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-6655
Practice Address - Country:US
Practice Address - Phone:619-642-7162
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman