Healthcare Provider Details

I. General information

NPI: 1164827135
Provider Name (Legal Business Name): MARK STEVEN LITTLE I.D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2014
Last Update Date: 11/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3D MARINE DIVISION UNIT 35801
FPO AP
96382-5801
US

IV. Provider business mailing address

3RD MARINE DIVISION
OKINAWA OKINAWA
9042171
JP

V. Phone/Fax

Practice location:
  • Phone: 949-767-7948
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: