MEDICARE: MR. DAVID GEORGE HAYNESNORTON 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	:	1174901433
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DAVID GEORGE HAYNESNORTON IDC

Provider Business Mailing Address
First Line	:	5 LAKE ST
Second Line	:
City	:	GROTON
State	:	CT
Zip	:	06340-3317
Country	:	US
Telephone Number	:	860-694-8226
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 LAKE ST
Second Line	:
City	:	GROTON
State	:	CT
Zip	:	06340-3317
Country	:	US
Telephone Number	:	860-694-8226
Fax Number	:

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

Provider Enumeration Date	:	05/07/2015
Last Update Date	:	05/07/2015

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Directions to “ MR. DAVID GEORGE HAYNESNORTON IDC” Practice Location

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