Provider Demographics
NPI:1558600569
Name:DRAKE, CALEB J (IDC)
Entity Type:Individual
Prefix:
First Name:CALEB
Middle Name:J
Last Name:DRAKE
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 1:1355 HELICOPTER RD BLDG 3812
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8937
Mailing Address - Country:US
Mailing Address - Phone:757-763-2190
Mailing Address - Fax:
Practice Address - Street 1:1355 HELICOPTER RD BLDG 3812
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8937
Practice Address - Country:US
Practice Address - Phone:757-763-2190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-11
Last Update Date:2013-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman