Provider Demographics
NPI:1164748174
Name:POPE, BRENT C (IDC)
Entity Type:Individual
Prefix:MR
First Name:BRENT
Middle Name:C
Last Name:POPE
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 1:2234 SW WARBLER WAY
Mailing Address - Street 2:
Mailing Address - City:PORT ORCHARD
Mailing Address - State:WA
Mailing Address - Zip Code:98367-6205
Mailing Address - Country:US
Mailing Address - Phone:360-874-0501
Mailing Address - Fax:
Practice Address - Street 1:PSC 451 BOX 340
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09834-2800
Practice Address - Country:US
Practice Address - Phone:9733-641-8157
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-15
Last Update Date:2010-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman