Provider Demographics
NPI:1730408691
Name:COULOMBE, MARK ANDREW (IDC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ANDREW
Last Name:COULOMBE
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:PO BOX 159
Mailing Address - Street 2:ATTN: NUMI
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06349-5159
Mailing Address - Country:US
Mailing Address - Phone:860-694-6467
Mailing Address - Fax:
Practice Address - Street 1:USS NEVADA
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96698-2114
Practice Address - Country:US
Practice Address - Phone:360-536-7611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-18
Last Update Date:2014-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman