Provider Demographics
NPI:1760814073
Name:VALTIERRA, ROBERT JESS III (IDC)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JESS
Last Name:VALTIERRA
Suffix:III
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 1:5310 REPECHO DR
Mailing Address - Street 2:APT V 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-1726
Mailing Address - Country:US
Mailing Address - Phone:808-224-4721
Mailing Address - Fax:
Practice Address - Street 1:SURFACE WARFARE MEDICAL INSTITUTE
Practice Address - Street 2:34101 FARENHOLT AVENUE, BUILDING 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-532-6195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-09
Last Update Date:2013-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman