Basic Information
| Provider Information | |||||||||
| NPI: | 1669012555 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CARMICAL | ||||||||
| FirstName: | JEREMY | ||||||||
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| Credential: | IDMT, USAF | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27 MAPLE AVE | ||||||||
| Address2: | |||||||||
| City: | SHALIMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325791111 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 340 BOATNER RD | ||||||||
| Address2: | |||||||||
| City: | EGLIN AFB | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325421391 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8508838600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/09/2020 | ||||||||
| LastUpdateDate: | 01/09/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/09/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1710I1003X | Y | Other Service Providers | Military Health Care Provider | Independent Duty Medical Technicians |
No ID Information.