Provider Demographics
NPI:1962724542
Name:CLOSE, CHARLES WILLIAM (IDC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:WILLIAM
Last Name:CLOSE
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:USS ALABAMA (SSBN-731)(BLUE)
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96698-2108
Mailing Address - Country:US
Mailing Address - Phone:360-315-4211
Mailing Address - Fax:360-396-6362
Practice Address - Street 1:USS ALABAMA (SSBN-731)(BLUE)
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96698-2108
Practice Address - Country:US
Practice Address - Phone:360-315-4211
Practice Address - Fax:360-396-6362
Is Sole Proprietor?:No
Enumeration Date:2010-02-23
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman