Provider Demographics
NPI:1558886242
Name:SMITH, BRANDON JAY (NAVY IDC)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:JAY
Last Name:SMITH
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 COLES FARM DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28546-8753
Mailing Address - Country:US
Mailing Address - Phone:312-800-3019
Mailing Address - Fax:
Practice Address - Street 1:E STREET BLDG G770
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28540
Practice Address - Country:US
Practice Address - Phone:312-800-3019
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-03
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman