Provider Demographics
NPI:1821189499
Name:GORMAN BALASCO, ROBERT W (IDC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:W
Last Name:GORMAN BALASCO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:ROBERT
Other - Middle Name:W
Other - Last Name:GORMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:IDC
Mailing Address - Street 1:NAVAL MEDICAL CTR
Mailing Address - Street 2:34800 BOB WILSON DRIVE
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-5000
Mailing Address - Country:US
Mailing Address - Phone:619-532-6666
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CTR
Practice Address - Street 2:34800 BOB WILSON DRIVE
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-5000
Practice Address - Country:US
Practice Address - Phone:619-532-6666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman