Healthcare Provider Details

I. General information

NPI: 1700451622
Provider Name (Legal Business Name): JOSE MIGUEL DE JESUS-CARRION
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSE MIGUEL DE JESUS

II. Dates (important events)

Enumeration Date: 05/24/2021
Last Update Date: 08/29/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BLDG A-71 SNEADS FERRY RD.
CAMP LEJEUNE NC
28542-0138
US

IV. Provider business mailing address

5-3845 COMBAT MEDIC DRIVE
FORT BRAGG NC
28310-9610
US

V. Phone/Fax

Practice location:
  • Phone: 910-440-7703
  • Fax:
Mailing address:
  • Phone: 910-394-1059
  • Fax:

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: