Individual
MATTHEW DEFRIES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
L02A
Contact information
Practice address
472 POLARIS ST BLDG 586, VIRGINIA BEACH, VA 23461-1935
(219) 869-1039
Mailing address
472 POLARIS ST BLDG 586, VIRGINIA BEACH, VA 23461-1935
Taxonomy
Speciality
Code
Description
License number
State
1710I1002X
Independent Duty Corpsman
Primary
5060000751
IN
Other
Enumeration date
03/06/2020
Last updated
06/22/2023
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