Healthcare Provider Details

I. General information

NPI: 1932533601
Provider Name (Legal Business Name): ERNESTO CARRASQUILLO III IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1804 CRESTMONT PLACE APT 302
CHESAPEAKE VA
23320
US

IV. Provider business mailing address

1804 CRESTMONT PLACE APT 302
CHESAPEAKE VA
23320
US

V. Phone/Fax

Practice location:
  • Phone: 757-651-7360
  • Fax:
Mailing address:
  • Phone: 757-651-7360
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: