1659612927 NPI number — MICHAEL OTHELLO MATHIS JR. SURFACE FORCE IDC

Table of content: MICHAEL OTHELLO MATHIS JR. SURFACE FORCE IDC (NPI 1659612927)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659612927 NPI number — MICHAEL OTHELLO MATHIS JR. SURFACE FORCE IDC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MATHIS
Provider First Name:
MICHAEL
Provider Middle Name:
OTHELLO
Provider Name Prefix Text:
Provider Name Suffix Text:
JR.
Provider Credential Text:
SURFACE FORCE 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:
1659612927
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
USS TRUXTUN
Provider Second Line Business Mailing Address:
DDG 103
Provider Business Mailing Address City Name:
FPO
Provider Business Mailing Address State Name:
AE
Provider Business Mailing Address Postal Code:
09588-1309
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
USS TRUXTUN
Provider Second Line Business Practice Location Address:
DDG 103
Provider Business Practice Location Address City Name:
FPO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09588-1309
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-445-6164
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/11/2013

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: 2865X1600X , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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