Provider Demographics
NPI:1336582774
Name:PHILLIPS, MARIO DELANO JR (IDC)
Entity type:Individual
Prefix:MR
First Name:MARIO
Middle Name:DELANO
Last Name:PHILLIPS
Suffix:JR
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:MARINE CORPS SECURITY FORCES
Mailing Address - Street 2:MCA 614 PORT AU PRINCE
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23551-0001
Mailing Address - Country:US
Mailing Address - Phone:757-444-6492
Mailing Address - Fax:
Practice Address - Street 1:745 EDEN WAY NORTH
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-560-2457
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-16
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman