Provider Demographics
NPI:1720352958
Name:PESCADOR, OMAR ANTONIO (IDC)
Entity Type:Individual
Prefix:
First Name:OMAR
Middle Name:ANTONIO
Last Name:PESCADOR
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 1:7568 ROARING SPRINGS RD
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-4269
Mailing Address - Country:US
Mailing Address - Phone:917-848-3454
Mailing Address - Fax:
Practice Address - Street 1:SEAL TEAM 10 MEDICAL DEPARTMENT
Practice Address - Street 2:BLDG 3808
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23521
Practice Address - Country:US
Practice Address - Phone:917-848-3454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman