Provider Demographics
NPI:1144858317
Name:MAHONEY, MICHAEL ROBERT JR (IDC)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ROBERT
Last Name:MAHONEY
Suffix:JR
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 1:9273 E BENT CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85747-5412
Mailing Address - Country:US
Mailing Address - Phone:636-634-6383
Mailing Address - Fax:
Practice Address - Street 1:34800 BOB WILSON DR STE 14
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-1014
Practice Address - Country:US
Practice Address - Phone:636-634-6383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-01
Last Update Date:2020-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman