Provider Demographics
NPI:1366618183
Name:CANTON, ROBERTO JUDAS (IDC US NAVY)
Entity type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:JUDAS
Last Name:CANTON
Suffix:
Gender:M
Credentials:IDC US NAVY
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35000 GUADACANAL ST
Mailing Address - Street 2:BMC MCRD BLDG 596
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92140-5599
Mailing Address - Country:US
Mailing Address - Phone:619-524-4039
Mailing Address - Fax:
Practice Address - Street 1:35000 GUADACANAL ST
Practice Address - Street 2:BMC MCRD BLDG 596
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92140-5599
Practice Address - Country:US
Practice Address - Phone:619-524-4039
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-01
Last Update Date:2008-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman