Healthcare Provider Details

I. General information

NPI: 1093741993
Provider Name (Legal Business Name): ELISHA ALEXANDER IDC US NAVY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1959 MORRIS ST SUITE 120 BLDG Z101
NORFOLK VA
23511-3427
US

IV. Provider business mailing address

1200 RENFREW ST
VIRGINIA BEACH VA
23464-8915
US

V. Phone/Fax

Practice location:
  • Phone: 757-443-0002
  • Fax: 757-443-5607
Mailing address:
  • Phone: 757-467-0561
  • Fax: 757-443-5706

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: