1710199666 NPI number — MR. MARK HALEY JOHNSON IDC

Table of content: MR. MARK HALEY JOHNSON IDC (NPI 1710199666)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710199666 NPI number — MR. MARK HALEY JOHNSON IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOHNSON
Provider First Name:
MARK
Provider Middle Name:
HALEY
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
IDC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1710199666
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/06/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
197 CHARTER OAK DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GROTON
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06340
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-865-0297
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
NLON MEDICAL DEPARTMENT BLDG 76
Provider Second Line Business Practice Location Address:
NAVAL SUBMARINE BASE
Provider Business Practice Location Address City Name:
GROTON
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06340
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-694-2795
Provider Business Practice Location Address Fax Number:
860-694-4326
Provider Enumeration Date:
05/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1002X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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