Provider Demographics
NPI:1588107916
Name:GIDARO, SHAWN (NAVTA VET ASS)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:GIDARO
Suffix:
Gender:M
Credentials:NAVTA VET ASS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3260 PRODUCTION AVE
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92058-1308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3260 PRODUCTION AVE
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92058-1308
Practice Address - Country:US
Practice Address - Phone:619-831-9221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-03
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA$$$$$$$$$AOtherMEDICARE