Dennis Buenaventura Custodio, INDEPENDENT DUTY HM

Key facts

NPI

1013264423

Entity type

Individual (NPI type 1)

Primary specialty

Independent Duty Corpsman 1710I1002X

Practice address

69 Trout Ave
Naval Undersea Medical Institute
Groton, CT 06349

Phone

(253) 905-8239

NPI assigned

Aug 6, 2012

Sex

Male

Sole proprietor

Yes

Medicare participation

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

National Provider Directory

Medicare enrollment (NPD)

No

Specialties & licenses

Addresses

The complete NPPES record for this NPI in the NPI Registry API JSON format, last updated by the provider on Aug 6, 2012.

{
    "created_epoch": "1344211200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1344211200000",
    "number": "1013264423",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "6910 227TH STREET CT E",
            "city": "SPANAWAY",
            "state": "WA",
            "postal_code": "983875841",
            "telephone_number": "253-905-8239"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "69 TROUT AVE",
            "address_2": "NAVAL UNDERSEA MEDICAL INSTITUTE",
            "city": "GROTON",
            "state": "CT",
            "postal_code": "06349",
            "telephone_number": "253-905-8239"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "CUSTODIO",
        "first_name": "DENNIS",
        "middle_name": "BUENAVENTURA",
        "credential": "INDEPENDENT DUTY HM",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2012-08-06",
        "last_updated": "2012-08-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "1710I1002X",
            "taxonomy_group": "",
            "desc": "Military Health Care Provider, Independent Duty Corpsman",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

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All providers in Groton, CT · Independent Duty Corpsman in Connecticut