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NPI Code Detail

MEDICARE: BRIAN THOMAS CLARK IDC

MEDICARE: BRIAN THOMAS CLARK IDC
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11710I1002XIndependent Duty Corpsman

General Provider Information

NPI Number : 1093744427
Entity Type Code : Individual
Provider Name (Legal Business Name) : BRIAN THOMAS CLARK IDC
Provider Business Mailing Address
First Line : 3972 SHADY OAKS DR
Second Line :
City : VIRGINIA BEACH
State : VA
Zip : 23455-1628
Country : US
Telephone Number : 757-630-7081
Fax Number :
Provider Business Practice Location Address
First Line : 3972 SHADY OAKS DR
Second Line :
City : VIRGINIA BEACH
State : VA
Zip : 23455-1628
Country : US
Telephone Number : 757-630-7081
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/30/2006
Last Update Date : 07/08/2007

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