Provider Demographics
NPI:1851116594
Name:DEFANTE, FERNAND MIGUEL (IDC)
Entity type:Individual
Prefix:
First Name:FERNAND MIGUEL
Middle Name:
Last Name:DEFANTE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3844 SWIFT AVE APT 3
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-3182
Mailing Address - Country:US
Mailing Address - Phone:619-609-5870
Mailing Address - Fax:
Practice Address - Street 1:3844 SWIFT AVE APT 3
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92104-3182
Practice Address - Country:US
Practice Address - Phone:619-609-5870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-18
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman