Provider Demographics
NPI:1841552163
Name:KERR, TIMOTHY J (DIVE IDC)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:J
Last Name:KERR
Suffix:
Gender:M
Credentials:DIVE IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4643 DOCK RD BLDG 524
Mailing Address - Street 2:
Mailing Address - City:PORT HUENEME
Mailing Address - State:CA
Mailing Address - Zip Code:93043-4321
Mailing Address - Country:US
Mailing Address - Phone:805-982-6682
Mailing Address - Fax:
Practice Address - Street 1:4643 DOCK RD BLDG 524
Practice Address - Street 2:
Practice Address - City:PORT HUENEME
Practice Address - State:CA
Practice Address - Zip Code:93043-4321
Practice Address - Country:US
Practice Address - Phone:805-982-6682
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-12
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman