Provider Demographics
NPI:1669672317
Name:CHUMPITAZ, MARTY
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:CHUMPITAZ
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 1:3597 CAMEO DR UNIT 2
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92056-6359
Mailing Address - Country:US
Mailing Address - Phone:619-889-2297
Mailing Address - Fax:
Practice Address - Street 1:1000 VALE TERRACE DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92084-5218
Practice Address - Country:US
Practice Address - Phone:760-407-1220
Practice Address - Fax:760-414-3711
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2008-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA952815615171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator