Provider Demographics
NPI:1306105069
Name:JONES, BRYAN EUGENE (SOIDC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:EUGENE
Last Name:JONES
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 COASTAL DR
Mailing Address - Street 2:
Mailing Address - City:N TOPSAIL BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28460-9535
Mailing Address - Country:US
Mailing Address - Phone:937-825-6648
Mailing Address - Fax:
Practice Address - Street 1:2D RECONNAISSANCE BN, 2D MARINE DIVISION BLDG A-71
Practice Address - Street 2:PSC BOX 20138
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:937-825-6648
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-15
Last Update Date:2012-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman