Provider Demographics
NPI:1811608656
Name:CALATRAVA, JOEFFREY MARIANO (IDC)
Entity type:Individual
Prefix:
First Name:JOEFFREY
Middle Name:MARIANO
Last Name:CALATRAVA
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 1:9TH ESB 3D MLG BMAT
Mailing Address - Street 2:UNIT 38430
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96385
Mailing Address - Country:US
Mailing Address - Phone:315-623-4526
Mailing Address - Fax:
Practice Address - Street 1:9TH ESB 3D MLG BMAT
Practice Address - Street 2:UNIT 38430
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96385
Practice Address - Country:US
Practice Address - Phone:315-623-4526
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2024-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program