Provider Demographics
NPI:1023330453
Name:DURGIN, RANDALL BRUCE (IDC)
Entity type:Individual
Prefix:
First Name:RANDALL
Middle Name:BRUCE
Last Name:DURGIN
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:BLDG 55 MEDICAL DEPT
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5029
Mailing Address - Country:US
Mailing Address - Phone:619-556-2724
Mailing Address - Fax:619-556-6756
Practice Address - Street 1:3325 SENN RD
Practice Address - Street 2:BLDG 55 MEDICAL DEPT
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5029
Practice Address - Country:US
Practice Address - Phone:619-556-2724
Practice Address - Fax:619-556-6756
Is Sole Proprietor?:No
Enumeration Date:2010-02-26
Last Update Date:2010-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman