Provider Demographics
NPI:1063649234
Name:STROTHENKE, JOHN MICHAEL (IDMT)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:MICHAEL
Last Name:STROTHENKE
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 1:2630 CENTRAL AVENUE SUITE 1
Mailing Address - Street 2:354 MEDICAL OPERATIONS SQUADRON, CLINICAL MEDICINE FLT
Mailing Address - City:EIELSON AIR FORCE BASE
Mailing Address - State:AK
Mailing Address - Zip Code:99702
Mailing Address - Country:US
Mailing Address - Phone:907-377-6657
Mailing Address - Fax:
Practice Address - Street 1:2630 CENTRAL AVENUE SUITE 1
Practice Address - Street 2:354 MEDICAL OPERATIONS SQUADRON, CLINICAL MEDICINE FLT
Practice Address - City:EIELSON AIR FORCE BASE
Practice Address - State:AK
Practice Address - Zip Code:99702
Practice Address - Country:US
Practice Address - Phone:907-377-6657
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1710I1003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians