Healthcare Provider Details

I. General information

NPI: 1619132669
Provider Name (Legal Business Name): GORDON DAVID BLAND JR. IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

NAVAL SUBMARINE BASE NEW LONDON
APO AE
06349-5000
US

IV. Provider business mailing address

94 PLANT ST
NEW LONDON CT
06320-4455
US

V. Phone/Fax

Practice location:
  • Phone: 860-694-3505
  • Fax: 860-694-4326
Mailing address:
  • Phone: 860-694-3505
  • Fax: 860-694-4326

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: