Provider Demographics
NPI:1003526989
Name:CALLICOAT, DANIEL JOHN (SOIDC)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:JOHN
Last Name:CALLICOAT
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:BLDG RR 361
Mailing Address - Street 2:
Mailing Address - City:CAMP LEJEUEN
Mailing Address - State:NC
Mailing Address - Zip Code:28540
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:BLDG RR 361
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:910-440-2504
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-01
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman