Healthcare Provider Details

I. General information

NPI: 1831124007
Provider Name (Legal Business Name): MICHAEL BRIAN SEXTON IDC MILITARY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

FPO AP 96662-2418 USS COLUMBUS SSN 762
PEARL HARBOR HI
96860
US

IV. Provider business mailing address

20 ELLIS ST
FREEHOLD NJ
07728-1810
US

V. Phone/Fax

Practice location:
  • Phone: 360-720-1096
  • Fax:
Mailing address:
  • Phone: 360-720-1096
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: