Provider Demographics
NPI:1457619025
Name:CAYANAN, JED VICENTE (SOIDC)
Entity Type:Individual
Prefix:MR
First Name:JED
Middle Name:VICENTE
Last Name:CAYANAN
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:BOX 555341
Mailing Address - Street 2:1ST MARINE SPECIAL OPERATIONS BATTALION
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5341
Mailing Address - Country:US
Mailing Address - Phone:760-725-5298
Mailing Address - Fax:
Practice Address - Street 1:BOX 555341
Practice Address - Street 2:1ST MARINE SPECIAL OPERATIONS BATTALION
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5341
Practice Address - Country:US
Practice Address - Phone:760-725-5298
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-02
Last Update Date:2012-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman