Provider Demographics
NPI:1104069210
Name:POPE, TRAVIS D (IDMT)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:D
Last Name:POPE
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 LIELMANIS AVE
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-5613
Mailing Address - Country:US
Mailing Address - Phone:850-881-3413
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-881-3413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-20
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1710I1003X
P8023941146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic