Provider Demographics
NPI:1770962409
Name:STATON, ROBERT (IDC)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:STATON
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 1:12 RHODE ISLAND LN
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-6134
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:SURFACE WARFARE MEDICAL INSTITUTE
Practice Address - Street 2:34101 FARENHOLT AVENUE, BUILDING 14
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:256-684-1661
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-27
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman