Provider Demographics
NPI:1316725633
Name:JORGENSEN, THOMAS CLEON (DEEP SEA DIVING IDC)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:CLEON
Last Name:JORGENSEN
Suffix:
Gender:M
Credentials:DEEP SEA DIVING IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4588 50TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92115-3305
Mailing Address - Country:US
Mailing Address - Phone:850-530-5141
Mailing Address - Fax:
Practice Address - Street 1:4588 50TH ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92115-3305
Practice Address - Country:US
Practice Address - Phone:850-530-5141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-18
Last Update Date:2023-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman