Shane S O'Brien, DEEP SEA DIVING IDC

Primary specialty

Military Health Care ProviderTaxonomy code 171000000X

Practice address

842 Georgia St
Imperial Beach, CA 91932-2343

Phone

(619) 869-1952

NPI assigned

Apr 10, 2019

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Electronic endpoints 1

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1554854400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1554854400000",
    "number": "1790248375",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "842 GEORGIA ST",
            "city": "IMPERIAL BEACH",
            "state": "CA",
            "postal_code": "919322343"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "842 GEORGIA ST",
            "city": "IMPERIAL BEACH",
            "state": "CA",
            "postal_code": "919322343",
            "telephone_number": "619-869-1952"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "O'BRIEN",
        "first_name": "SHANE",
        "middle_name": "S",
        "credential": "DEEP SEA DIVING IDC",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2019-04-10",
        "last_updated": "2019-04-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "171000000X",
            "taxonomy_group": "193400000X SINGLE SPECIALTY  GROUP",
            "desc": "Military Health Care Provider",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "CONNECT",
            "endpointTypeDescription": "CONNECT URL",
            "endpoint": "Shane.s.obrien.mil@mail.mil",
            "affiliation": "N",
            "address_1": "842 Georgia St",
            "city": "Imperial Beach",
            "state": "CA",
            "country_code": "US",
            "postal_code": "919322343",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

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• Military Health Care Provider in Imperial Beach, CA
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• Military Health Care Provider in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.