Provider Demographics
NPI:1669012555
Name:CARMICAL, JEREMY (IDMT, USAF)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:
Last Name:CARMICAL
Suffix:
Gender:M
Credentials:IDMT, USAF
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27 MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:SHALIMAR
Mailing Address - State:FL
Mailing Address - Zip Code:32579-1111
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:340 BOATNER RD
Practice Address - Street 2:
Practice Address - City:EGLIN AFB
Practice Address - State:FL
Practice Address - Zip Code:32542-1391
Practice Address - Country:US
Practice Address - Phone:850-883-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians