Provider Demographics
NPI:1902120736
Name:CALIBOSO, BENITO MANGROBANG JR (IDMT)
Entity Type:Individual
Prefix:
First Name:BENITO
Middle Name:MANGROBANG
Last Name:CALIBOSO
Suffix:JR
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 SAN MARINO AVE
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2656
Mailing Address - Country:US
Mailing Address - Phone:707-557-6210
Mailing Address - Fax:
Practice Address - Street 1:330 SAN MARINO AVE
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94589-2656
Practice Address - Country:US
Practice Address - Phone:707-557-6210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-23
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians