Provider Demographics
NPI:1942618830
Name:WARDEN, MICHAEL (IDC)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WARDEN
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 1:3325 SENN RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5029
Mailing Address - Country:US
Mailing Address - Phone:760-401-0661
Mailing Address - Fax:
Practice Address - Street 1:3325 SENN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5029
Practice Address - Country:US
Practice Address - Phone:760-401-0661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-24
Last Update Date:2019-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman