Provider Demographics
NPI:1891949616
Name:SHOULDERS, TERRY DWAYNE (IDC)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:DWAYNE
Last Name:SHOULDERS
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 1:3375 GREGORY ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-4751
Mailing Address - Country:US
Mailing Address - Phone:760-668-5569
Mailing Address - Fax:
Practice Address - Street 1:3402 TARAWA RD.
Practice Address - Street 2:SPECIAL BOAT TEAM TWELVE MEDICAL DEPARTMENT
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-5003
Practice Address - Country:US
Practice Address - Phone:619-437-5540
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-06
Last Update Date:2008-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman