Provider Demographics
NPI:1558500090
Name:OVERLIE, SEAN PATRICK (IDC)
Entity type:Individual
Prefix:
First Name:SEAN
Middle Name:PATRICK
Last Name:OVERLIE
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 1:2496 BAUER RD.
Mailing Address - Street 2:BMC MCAS MIRAMAR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92145
Mailing Address - Country:US
Mailing Address - Phone:858-577-9864
Mailing Address - Fax:858-577-9965
Practice Address - Street 1:2496 BAUER RD.
Practice Address - Street 2:BMC MCAS MIRAMAR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92145
Practice Address - Country:US
Practice Address - Phone:858-577-9864
Practice Address - Fax:858-577-9965
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-06
Last Update Date:2009-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman