Provider Demographics
NPI:1265817175
Name:BADILLO, ADAM (IDC)
Entity Type:Individual
Prefix:MR
First Name:ADAM
Middle Name:
Last Name:BADILLO
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 1:600 MERIDIAN STREET EXT APT 1415
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-4160
Mailing Address - Country:US
Mailing Address - Phone:619-717-1658
Mailing Address - Fax:
Practice Address - Street 1:600 MERIDIAN STREET EXT APT 1415
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06340-4160
Practice Address - Country:US
Practice Address - Phone:619-717-1658
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-22
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF44774361710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman