Provider Demographics
NPI:1235673054
Name:BURGESS, JOHN LAYNE (SOIDC)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LAYNE
Last Name:BURGESS
Suffix:
Gender:M
Credentials:SOIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D MARINE RAIDER BATTALION
Mailing Address - Street 2:PSC BOX 20183
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0183
Mailing Address - Country:US
Mailing Address - Phone:208-312-1165
Mailing Address - Fax:
Practice Address - Street 1:2D MARINE RAIDER BATTALION
Practice Address - Street 2:PSC BOX 20183
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0183
Practice Address - Country:US
Practice Address - Phone:208-312-1165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-13
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman