Provider Demographics
NPI:1689934879
Name:NUCUP, NEIL ALLEN REGERO (IDC)
Entity Type:Individual
Prefix:
First Name:NEIL ALLEN
Middle Name:REGERO
Last Name:NUCUP
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 1:1802 ROCKY SHORE RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-1017
Mailing Address - Country:US
Mailing Address - Phone:619-434-1163
Mailing Address - Fax:
Practice Address - Street 1:1802 ROCKY SHORE RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92139-1017
Practice Address - Country:US
Practice Address - Phone:619-434-1163
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-21
Last Update Date:2012-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman