Provider Demographics
NPI:1780928168
Name:SAWYER, JEREMIAH CLYDE (IDC)
Entity type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:CLYDE
Last Name:SAWYER
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 1:4050 SURFACE NAVY BLVD
Mailing Address - Street 2:MUDSU ONE DET-1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92136-5288
Mailing Address - Country:US
Mailing Address - Phone:619-556-6323
Mailing Address - Fax:
Practice Address - Street 1:4050 SURFACE NAVY BLVD
Practice Address - Street 2:MUDSU ONE DET-1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92136-5288
Practice Address - Country:US
Practice Address - Phone:619-556-6323
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-25
Last Update Date:2012-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman