Provider Demographics
NPI:1922203611
Name:BASILIO, LORENZO F III (SFIDC)
Entity Type:Individual
Prefix:MR
First Name:LORENZO
Middle Name:F
Last Name:BASILIO
Suffix:III
Gender:M
Credentials:SFIDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 80 BOX 10436
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AP
Mailing Address - Zip Code:96367
Mailing Address - Country:JP
Mailing Address - Phone:098-959-3024
Mailing Address - Fax:
Practice Address - Street 1:3D MEDICAL BN
Practice Address - Street 2:BRAVO COMPANY
Practice Address - City:CAMP HANSEN
Practice Address - State:OKINAWA
Practice Address - Zip Code:96604
Practice Address - Country:JP
Practice Address - Phone:315-623-4681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman