Provider Demographics
NPI:1841539376
Name:DESOTO, BRIAN C
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:C
Last Name:DESOTO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 BAKKE ST
Mailing Address - Street 2:
Mailing Address - City:HURLBURT FIELD
Mailing Address - State:FL
Mailing Address - Zip Code:32544-1046
Mailing Address - Country:US
Mailing Address - Phone:850-226-3882
Mailing Address - Fax:
Practice Address - Street 1:113 LIELMANIS AVE
Practice Address - Street 2:
Practice Address - City:HURLBURT FIELD
Practice Address - State:FL
Practice Address - Zip Code:32544-5613
Practice Address - Country:US
Practice Address - Phone:850-881-4595
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-04
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians