Healthcare Provider Details

I. General information

NPI: 1235181058
Provider Name (Legal Business Name): DANIEL WILLIAM FEEBACK IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/17/2006
Last Update Date: 12/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 JOHN PAUL JONES CIR NAVAL MEDICAL CENTER PORTSMOUTH MEDICAL DEPARTMENT(CODE NO2M)
NORFOLK VA
23511-2419
US

IV. Provider business mailing address

4121 SHORELINE CIR APT 118
VIRGINIA BEACH VA
23452-2165
US

V. Phone/Fax

Practice location:
  • Phone: 757-443-0026
  • Fax: 757-443-5706
Mailing address:
  • Phone: 757-469-9642
  • 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: