1518635978 NPI number — MR. JESSE DANIEL OSTERMANN SOIDC

Table of content: MR. JESSE DANIEL OSTERMANN SOIDC (NPI 1518635978)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518635978 NPI number — MR. JESSE DANIEL OSTERMANN SOIDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OSTERMANN
Provider First Name:
JESSE
Provider Middle Name:
DANIEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
SOIDC
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:
1518635978
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1510 S HILL AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FALLBROOK
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92028-4049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-745-7045
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
BLDG 4101 1ST RECONNAISSANCE BAS
Provider Second Line Business Practice Location Address:
41 AREA, LAS FLORES
Provider Business Practice Location Address City Name:
CAMP PENDELTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92055-5584
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
760-725-8912
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/01/2021

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)





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