Provider Demographics
NPI:1669602298
Name:BARTLETT, CHRISTOPHER AVERY (IDC)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:AVERY
Last Name:BARTLETT
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 1:17 HUTCHINS ST
Mailing Address - Street 2:
Mailing Address - City:SANTA RITA
Mailing Address - State:GU
Mailing Address - Zip Code:96915-1163
Mailing Address - Country:US
Mailing Address - Phone:671-727-0836
Mailing Address - Fax:
Practice Address - Street 1:PSC 455 BOX 152
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96540-0152
Practice Address - Country:US
Practice Address - Phone:671-339-7143
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-16
Last Update Date:2012-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710L1002X1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman