Provider Demographics
NPI:1205268349
Name:TANJUAQUIO, MAURICE KIM (IDC)
Entity type:Individual
Prefix:MR
First Name:MAURICE
Middle Name:KIM
Last Name:TANJUAQUIO
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 1:3913 INGRAHAM ST APT U309
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5918
Mailing Address - Country:US
Mailing Address - Phone:619-518-4329
Mailing Address - Fax:
Practice Address - Street 1:3913 INGRAHAM ST APT U309
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5918
Practice Address - Country:US
Practice Address - Phone:619-518-4329
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman