Provider Demographics
NPI:1013264597
Name:DEZERN, SHAUN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:SHAUN
Middle Name:CHRISTOPHER
Last Name:DEZERN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2D RECON BN, A-71
Mailing Address - Street 2:MEDICAL DEPARTMENT
Mailing Address - City:CAMP LEJEUNE
Mailing Address - State:NC
Mailing Address - Zip Code:28542-0138
Mailing Address - Country:US
Mailing Address - Phone:910-440-7712
Mailing Address - Fax:
Practice Address - Street 1:2D RECON BN, A-71
Practice Address - Street 2:MEDICAL DEPARTMENT
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-440-7712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman