Provider Demographics
NPI:1134352719
Name:PUROG, EDINITO GULFAN (IDC)
Entity type:Individual
Prefix:
First Name:EDINITO
Middle Name:GULFAN
Last Name:PUROG
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 1:1888 CROSSROADS ST
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-2430
Mailing Address - Country:US
Mailing Address - Phone:619-852-6601
Mailing Address - Fax:
Practice Address - Street 1:1888 CROSSROADS ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91915-2430
Practice Address - Country:US
Practice Address - Phone:619-852-6601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-28
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman