Provider Demographics
NPI:1710276480
Name:MONROE, MICHAEL (IDC)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:MONROE
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 1:2520 MIDWAY RD, STE 200
Mailing Address - Street 2:EODMU TWO MEDICAL DEPT
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459
Mailing Address - Country:US
Mailing Address - Phone:757-462-8452
Mailing Address - Fax:
Practice Address - Street 1:2520 MIDWAY RD, STE 200
Practice Address - Street 2:EODMU TWO MEDICAL DEPT
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459
Practice Address - Country:US
Practice Address - Phone:757-462-8452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2011-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman