MEDICARE: ROBERT TODD POWELL 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
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1922061142
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROBERT TODD POWELL IDC

Provider Business Mailing Address
First Line	:	BLDG2
Second Line	:	DESTROYER SQUADRON FOURTEEN MEDICAL
City	:	MAYPORT
State	:	FL
Zip	:	32228
Country	:	US
Telephone Number	:	904-270-5524
Fax Number	:	904-270-7038

Provider Business Practice Location Address
First Line	:	14090 CRESTWICK DR E
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32218-8432
Country	:	US
Telephone Number	:	904-751-7463
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2006
Last Update Date	:	07/08/2007

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