Healthcare Provider Details

I. General information

NPI: 1821089806
Provider Name (Legal Business Name): MARC LAURENCE DAYMUDE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2005
Last Update Date: 01/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

BROOKE ARMY MEDICAL CENTER, MCHE-QD/CREDENTIALS 3851 ROGER BROOKE DR.
FORT SAM HOUSTON TX
78234-6200
US

IV. Provider business mailing address

BROOKE ARMY MEDICAL CENTER, MCHE-QD/CREDENTIALS 3851 ROGER BROOKE DR.
FORT SAM HOUSTON TX
78234-6200
US

V. Phone/Fax

Practice location:
  • Phone: 210-916-4626
  • Fax: 210-916-2265
Mailing address:
  • Phone: 210-916-4626
  • Fax: 210-916-2265

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number9600332
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: