Healthcare Provider Details

I. General information

NPI: 1821225913
Provider Name (Legal Business Name): ALTON E DOE JR. IDMT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 06/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2630 CENTRAL AVE STE 1
EIELSON AFB AK
99702-2301
US

IV. Provider business mailing address

3349 CENTRAL AVE
EIELSON AIR FORCE BAS AK
99702
US

V. Phone/Fax

Practice location:
  • Phone: 907-377-4326
  • Fax:
Mailing address:
  • Phone: 907-377-4326
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1003X
TaxonomyIndependent Duty Medical Technicians
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: