Provider Demographics
NPI:1063645208
Name:SEERY, SHANE JEROME (IDC)
Entity Type:Individual
Prefix:MR
First Name:SHANE
Middle Name:JEROME
Last Name:SEERY
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
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Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PSC BOX 555223
Mailing Address - Street 2:NAVAL EXPEDITIONARY MEDICAL TRAINING INSTITUTE
Mailing Address - City:CAMP PENDLETON
Mailing Address - State:CA
Mailing Address - Zip Code:92055-5223
Mailing Address - Country:US
Mailing Address - Phone:760-725-7121
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 632044 CHRISTIANITOS ROAD
Practice Address - Street 2:NAVAL EXPEDITIONARY MEDICAL TRAINING INSTITUTE
Practice Address - City:CAMP PENDLETON
Practice Address - State:CA
Practice Address - Zip Code:92055
Practice Address - Country:US
Practice Address - Phone:760-725-7121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman