Provider Demographics
NPI:1871903476
Name:ROMAN, GILBERT (IDC)
Entity type:Individual
Prefix:
First Name:GILBERT
Middle Name:
Last Name:ROMAN
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 1:3355 JORDAN PL
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-2007
Mailing Address - Country:US
Mailing Address - Phone:619-818-5743
Mailing Address - Fax:
Practice Address - Street 1:USS VANDEGRIFT FFG 48
Practice Address - Street 2:NAVAL STATION 32ND ST
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-2007
Practice Address - Country:US
Practice Address - Phone:619-556-4740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-05
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB80315021710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman