Provider Demographics
NPI:1265786156
Name:MCINTOSH, KYLE JOSEPH (IDC)
Entity type:Individual
Prefix:MR
First Name:KYLE
Middle Name:JOSEPH
Last Name:MCINTOSH
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 1:5803 RILEY ST
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-1729
Mailing Address - Country:US
Mailing Address - Phone:352-875-7052
Mailing Address - Fax:
Practice Address - Street 1:5803 RILEY ST
Practice Address - Street 2:UNIT 2
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-1729
Practice Address - Country:US
Practice Address - Phone:352-875-7052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-31
Last Update Date:2012-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman