Provider Demographics
NPI:1841636313
Name:LADD, GEORGE ALAN (IDC)
Entity type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:ALAN
Last Name:LADD
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5320 FAN PALM AVE
Mailing Address - Street 2:
Mailing Address - City:COCOA
Mailing Address - State:FL
Mailing Address - Zip Code:32927-2004
Mailing Address - Country:US
Mailing Address - Phone:305-491-3062
Mailing Address - Fax:
Practice Address - Street 1:2D MARDIV
Practice Address - Street 2:PSC BOX 2088
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542
Practice Address - Country:US
Practice Address - Phone:910-451-2789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-10
Last Update Date:2013-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Provider Identifiers
StateIdentifier IDID TypeIssuer
1710-1002XOtherIDC