Provider Demographics
NPI:1790008019
Name:PHIBBS, ROGER DALE JR (IDC)
Entity Type:Individual
Prefix:
First Name:ROGER
Middle Name:DALE
Last Name:PHIBBS
Suffix:JR
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:MEDICAL DEPARTMENT
Mailing Address - Street 2:USS MASON (DDG 87)
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09578-1302
Mailing Address - Country:US
Mailing Address - Phone:757-444-7400
Mailing Address - Fax:
Practice Address - Street 1:USS MASON (DDG 87)
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09578-1302
Practice Address - Country:US
Practice Address - Phone:757-444-7400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-02
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman