Provider Demographics
NPI:1205174752
Name:CAYANAN, CELSO VILLANUEVA
Entity type:Individual
Prefix:
First Name:CELSO
Middle Name:VILLANUEVA
Last Name:CAYANAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 CUSHING ROAD
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:92106
Mailing Address - Country:US
Mailing Address - Phone:619-524-5733
Mailing Address - Fax:
Practice Address - Street 1:2051 CUSHING RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92106-6173
Practice Address - Country:US
Practice Address - Phone:619-524-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-17
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA000000000000000000001710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman