Provider Demographics
NPI:1376194274
Name:SMITH, CHRISTOPHER LEE ROY (SUBMARINE IDC)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:LEE ROY
Last Name:SMITH
Suffix:
Gender:M
Credentials:SUBMARINE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 BAYBERRY HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-1435
Mailing Address - Country:US
Mailing Address - Phone:910-650-4616
Mailing Address - Fax:
Practice Address - Street 1:USS SAN JUAN (SSN 751)
Practice Address - Street 2:
Practice Address - City:GROTON
Practice Address - State:CT
Practice Address - Zip Code:06349
Practice Address - Country:US
Practice Address - Phone:910-650-4616
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-23
Last Update Date:2019-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman