Provider Demographics
NPI:1154766673
Name:HESS, JUSTIN BRIAN (IDC)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:BRIAN
Last Name:HESS
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 1:1870 GATOR BLVD
Mailing Address - Street 2:BUILDING 3842
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8900
Mailing Address - Country:US
Mailing Address - Phone:757-763-2560
Mailing Address - Fax:
Practice Address - Street 1:1870 GATOR BLVD
Practice Address - Street 2:BUILDING 3842
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8900
Practice Address - Country:US
Practice Address - Phone:757-763-2560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman