Healthcare Provider Details

I. General information

NPI: 1528210374
Provider Name (Legal Business Name): JOHN WESLEY HUCKLEBERRY II HMC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 04/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 100236 DRAWER 2703 USS DWIGHT D EISENHOWER CVN 69
FPO AE
09532-3627
US

IV. Provider business mailing address

PO BOX 15274
NORFOLK VA
23511-0274
US

V. Phone/Fax

Practice location:
  • Phone: 757-443-7842
  • Fax:
Mailing address:
  • Phone: 614-657-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: