Provider Demographics
NPI:1629301361
Name:THOMAS, BOBBY O (IDC)
Entity Type:Individual
Prefix:MR
First Name:BOBBY
Middle Name:O
Last Name:THOMAS
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 1:1300 HELICOPTER RD
Mailing Address - Street 2:NAVAL SPECIAL WARFARE SUPPORT ACTIVITY TWO
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23521-2936
Mailing Address - Country:US
Mailing Address - Phone:757-763-2508
Mailing Address - Fax:
Practice Address - Street 1:1300 HELICOPTER RD
Practice Address - Street 2:NAVAL SPECIAL WARFARE SUPPORT ACTIVITY TWO
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23521-2936
Practice Address - Country:US
Practice Address - Phone:757-763-2508
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-14
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman