Provider Demographics
NPI:1114273596
Name:DAVIS, BRETT CORY (IDC)
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:CORY
Last Name:DAVIS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MEDICAL BATTALION PSC BOX 20129
Mailing Address - Street 2:CHARLIE SURGICAL COMPANY
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0129
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2D MEDICAL BATTALION PSC BOX 20129
Practice Address - Street 2:CHARLIE SURGICAL COMPANY
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0129
Practice Address - Country:US
Practice Address - Phone:847-848-6781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman