1023330453 NPI number — RANDALL BRUCE DURGIN IDC

Table of content: RANDALL BRUCE DURGIN IDC (NPI 1023330453)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023330453 NPI number — RANDALL BRUCE DURGIN IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DURGIN
Provider First Name:
RANDALL
Provider Middle Name:
BRUCE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023330453
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/26/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3325 SENN RD
Provider Second Line Business Mailing Address:
BLDG 55 MEDICAL DEPT
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92136-5029
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-556-2724
Provider Business Mailing Address Fax Number:
619-556-6756

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3325 SENN RD
Provider Second Line Business Practice Location Address:
BLDG 55 MEDICAL DEPT
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92136-5029
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-556-2724
Provider Business Practice Location Address Fax Number:
619-556-6756
Provider Enumeration Date:
02/26/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)