Provider Demographics
NPI:1720144652
Name:BERCIDE, EARL GASTADOR (IDC, USN)
Entity Type:Individual
Prefix:
First Name:EARL
Middle Name:GASTADOR
Last Name:BERCIDE
Suffix:
Gender:M
Credentials:IDC, USN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 FULLER ROAD
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39305-5104
Mailing Address - Country:US
Mailing Address - Phone:601-679-2633
Mailing Address - Fax:
Practice Address - Street 1:1801 FULLER RD
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39309-5107
Practice Address - Country:US
Practice Address - Phone:601-679-2633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman