Provider Demographics
NPI:1316336258
Name:TALAVERA, JORGE E (IDC)
Entity type:Individual
Prefix:MR
First Name:JORGE
Middle Name:E
Last Name:TALAVERA
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:MR
Other - First Name:JORGE
Other - Middle Name:E
Other - Last Name:TALAVERA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:IDC
Mailing Address - Street 1:3875 FLORIDA ST APT 2
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-6241
Mailing Address - Country:US
Mailing Address - Phone:760-585-8030
Mailing Address - Fax:
Practice Address - Street 1:3875 FLORIDA ST APT 2
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104
Practice Address - Country:US
Practice Address - Phone:760-585-8030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman