Provider Demographics
NPI:1932161197
Name:GUADEZ, REYNALDO ALDOVER (IDC)
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:ALDOVER
Last Name:GUADEZ
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 1:7479 LINDA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92111-5833
Mailing Address - Country:US
Mailing Address - Phone:619-524-4045
Mailing Address - Fax:
Practice Address - Street 1:BRANCH MEDICAL CLINIC MCRD
Practice Address - Street 2:35000 GUADALCANAL STREET
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140
Practice Address - Country:US
Practice Address - Phone:619-524-4045
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman