Provider Demographics
NPI:1588006878
Name:O'HARE, JON RYAN (IDC)
Entity type:Individual
Prefix:MR
First Name:JON
Middle Name:RYAN
Last Name:O'HARE
Suffix:
Gender:
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7749 CALLE ANDAR
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92009-9227
Mailing Address - Country:US
Mailing Address - Phone:760-585-6160
Mailing Address - Fax:
Practice Address - Street 1:SPECIAL BOAT TEAM TWELVE 3402 TARAWA ROAD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92155-9227
Practice Address - Country:US
Practice Address - Phone:619-437-5540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-26
Last Update Date:2025-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider