Provider Demographics
NPI:1881618346
Name:NAVAL HOSPITAL JACKSONVILLE
Entity type:Organization
Organization Name:NAVAL HOSPITAL JACKSONVILLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO
Authorized Official - Prefix:
Authorized Official - First Name:RAQUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BONO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-542-7787
Mailing Address - Street 1:3220 E 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LYNN HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:32444-3236
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:NAVAL HOSPITAL JACKSONVILLE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32099
Practice Address - Country:US
Practice Address - Phone:904-542-7787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34006688207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAD0000Medicare UPIN