Basic Information
Provider Information | |||||||||
NPI: | 1851460935 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NAVAL HOSPITAL OKINAWA | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | BLDG 6000 | ||||||||
Address2: | CAMP LESTER JAPAN | ||||||||
City: | FPO | ||||||||
State: | AP | ||||||||
PostalCode: | 96362 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | BLDG 6000 | ||||||||
Address2: | CAMP LESTER JAPAN | ||||||||
City: | FPO | ||||||||
State: | AP | ||||||||
PostalCode: | 96362 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2105366650 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/06/2006 | ||||||||
LastUpdateDate: | 04/10/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CONDON | ||||||||
AuthorizedOfficialFirstName: | WILLIAM | ||||||||
AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
AuthorizedOfficialTitleorPosition: | NAVY MEDICINE UBO PROGRAM MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2404013643 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | Y | ||||||||
ParentOrganizationLBN: | NAVAL HOSPITAL OKINAWA | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332000000X |   |   | Y |   | Suppliers | Military/U.S. Coast Guard Pharmacy |   |
ID Information
ID | Type | State | Issuer | Description | 2114122 | 01 |   | PK | OTHER |