Provider Demographics
NPI:1801091285
Name:ENGLE, RICHARD JUSTIN (NAVY IDC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:JUSTIN
Last Name:ENGLE
Suffix:
Gender:M
Credentials:NAVY IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5128
Mailing Address - Country:US
Mailing Address - Phone:678-656-8999
Mailing Address - Fax:
Practice Address - Street 1:2ND BATTALION 9TH MARINES BLDG. 514
Practice Address - Street 2:2ND MARINE DIVISION
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-450-9431
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1710I1002X1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman