Provider Demographics
NPI:1336716364
Name:WILTERS, HARRY STONE (SOIDC)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:STONE
Last Name:WILTERS
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 555341
Mailing Address - Street 2:
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5341
Mailing Address - Country:US
Mailing Address - Phone:760-725-6579
Mailing Address - Fax:
Practice Address - Street 1:26033 CAPE DR
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-0914
Practice Address - Country:US
Practice Address - Phone:251-504-7536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-08
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1453970546OtherDODID