Provider Demographics
NPI:1194336842
Name:SILVA, JORGE LUIS (IDC)
Entity type:Individual
Prefix:
First Name:JORGE
Middle Name:LUIS
Last Name:SILVA
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:PO BOX 128
Mailing Address - Street 2:
Mailing Address - City:KEKAHA
Mailing Address - State:HI
Mailing Address - Zip Code:96752-0128
Mailing Address - Country:US
Mailing Address - Phone:949-619-0863
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 128
Practice Address - Street 2:
Practice Address - City:KEKAHA
Practice Address - State:HI
Practice Address - Zip Code:96752-0128
Practice Address - Country:US
Practice Address - Phone:949-619-0863
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-14
Last Update Date:2025-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1002X
CA11943368421710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman