Provider Demographics
NPI:1154491132
Name:VIRDELL, GARY MATTHEW (IDC)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MATTHEW
Last Name:VIRDELL
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3606 HUBLY RD
Mailing Address - Street 2:
Mailing Address - City:STANWOOD
Mailing Address - State:WA
Mailing Address - Zip Code:98292
Mailing Address - Country:US
Mailing Address - Phone:360-652-2894
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HEALTH CLINIC, NAVAL STATION EVERETT
Practice Address - Street 2:BLDG 2110
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98207
Practice Address - Country:US
Practice Address - Phone:425-304-4076
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman