MEDICARE: DAVID JONATHAN HARTZELL IDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1164673398
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID JONATHAN HARTZELL IDC

Provider Business Mailing Address
First Line	:	2521 ALLEGHANY LOOP
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-2442
Country	:	US
Telephone Number	:	240-481-4429
Fax Number	:

Provider Business Practice Location Address
First Line	:	2521 ALLEGHANY LOOP
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23456-2442
Country	:	US
Telephone Number	:	240-481-4429
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/07/2008
Last Update Date	:	10/07/2008

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