Provider Demographics
NPI:1588877963
Name:DERTINA, DAMON MARCUS (MD)
Entity type:Individual
Prefix:
First Name:DAMON
Middle Name:MARCUS
Last Name:DERTINA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34800 BOB WILSON DR STE 409
Mailing Address - Street 2:DEPT OF ANESTHESIOLOGY, NAVAL MEDICAL CENTER SAN DIEGO
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92134-1409
Mailing Address - Country:US
Mailing Address - Phone:619-453-6922
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR STE 409
Practice Address - Street 2:DEPT OF ANESTHESIOLOGY, NAVAL MEDICAL CENTER SAN DIEGO
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1409
Practice Address - Country:US
Practice Address - Phone:619-453-6922
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA98936207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1588877963Medicaid
CA00A989360OtherBLUE SHIELD OF CA
CA1588877963Medicaid
CAI74073Medicare UPIN
CA00A989360OtherBLUE SHIELD OF CA