Provider Demographics
NPI:1700451622
Name:DE JESUS-CARRION, JOSE MIGUEL
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:MIGUEL
Last Name:DE JESUS-CARRION
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOSE
Other - Middle Name:MIGUEL
Other - Last Name:DE JESUS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5-3845 COMBAT MEDIC DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT BRAGG
Mailing Address - State:NC
Mailing Address - Zip Code:28310-9610
Mailing Address - Country:US
Mailing Address - Phone:910-394-1059
Mailing Address - Fax:
Practice Address - Street 1:BLDG A-71 SNEADS FERRY RD.
Practice Address - Street 2:
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0138
Practice Address - Country:US
Practice Address - Phone:910-440-7703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-24
Last Update Date:2023-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman