Provider Demographics
NPI:1780815472
Name:GATRELL, LARRY CHARLES JR (SUB IDC)
Entity type:Individual
Prefix:MR
First Name:LARRY
Middle Name:CHARLES
Last Name:GATRELL
Suffix:JR
Gender:M
Credentials:SUB IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:USS CITY OF CORPUS CHRISTI # 705
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96662-2385
Mailing Address - Country:US
Mailing Address - Phone:671-777-9343
Mailing Address - Fax:
Practice Address - Street 1:USS CITY OF CORPUS CHRISTI # 705
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96662-2385
Practice Address - Country:US
Practice Address - Phone:671-777-9343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2009-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman