Provider Demographics
NPI:1073812095
Name:STALEY, ERIC WILLIAM (NAVY IDC)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:WILLIAM
Last Name:STALEY
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7958 BLANDY ROAD
Mailing Address - Street 2:COMMANDER SUBMARINE FORCE ATLANTIC
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23551-2492
Mailing Address - Country:US
Mailing Address - Phone:757-836-1351
Mailing Address - Fax:757-836-1352
Practice Address - Street 1:7958 BLANDY ROAD
Practice Address - Street 2:COMMANDER SUBMARINE FORCE ATLANTIC
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23551-2492
Practice Address - Country:US
Practice Address - Phone:757-836-1351
Practice Address - Fax:757-836-1352
Is Sole Proprietor?:No
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman