Provider Demographics
NPI:1003140344
Name:COUCH, CHRISTOPHER SHAWN (IDMT)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:SHAWN
Last Name:COUCH
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:718 I AVE 82 MSS/DPF
Mailing Address - Street 2:BLDG 1900 DEPT XUFB
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311
Mailing Address - Country:US
Mailing Address - Phone:940-676-3818
Mailing Address - Fax:
Practice Address - Street 1:718 I AVE 82 MSS/DPF
Practice Address - Street 2:BLDG 1900 DEPT XUFB
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311
Practice Address - Country:US
Practice Address - Phone:940-676-3818
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-18
Last Update Date:2009-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians