Provider Demographics
NPI:1922209204
Name:BLEDSOE, STEVEN LEE (IDC)
Entity type:Individual
Prefix:
First Name:STEVEN
Middle Name:LEE
Last Name:BLEDSOE
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:CLR-17 RAS, 1ST MLG
Mailing Address - Street 2:PO BOX 555607
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5607
Mailing Address - Country:US
Mailing Address - Phone:760-725-6180
Mailing Address - Fax:
Practice Address - Street 1:CLR-17 RAS, 1ST MLG
Practice Address - Street 2:BLDG 14030
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055-5607
Practice Address - Country:US
Practice Address - Phone:760-725-6180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman