Provider Demographics
NPI:1285682401
Name:DEGENHARDT, TOBY JASON (PT)
Entity Type:Individual
Prefix:
First Name:TOBY
Middle Name:JASON
Last Name:DEGENHARDT
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 BREWSTER BLVD
Mailing Address - Street 2:NAVAL HOSPITAL
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28547-2538
Mailing Address - Country:US
Mailing Address - Phone:910-450-4159
Mailing Address - Fax:910-450-4194
Practice Address - Street 1:100 BREWSTER BLVD
Practice Address - Street 2:100 BREWSTER BLVD
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28547-2538
Practice Address - Country:US
Practice Address - Phone:910-450-4159
Practice Address - Fax:910-450-4194
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1153286171000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider