Provider Demographics
NPI:1790097426
Name:MORRIS, REGINALD JR (IDC)
Entity Type:Individual
Prefix:MR
First Name:REGINALD
Middle Name:
Last Name:MORRIS
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 1:1575 GATOR BLVD STE 150
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23459-8744
Mailing Address - Country:US
Mailing Address - Phone:757-462-4316
Mailing Address - Fax:
Practice Address - Street 1:1575 GATOR BLVD STE 150
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8744
Practice Address - Country:US
Practice Address - Phone:757-462-4316
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-10
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman