Provider Demographics
NPI:1144103292
Name:BJOTVEDT, HAARIS GEORGE (SOIDC (SO-ATP))
Entity type:Individual
Prefix:
First Name:HAARIS
Middle Name:GEORGE
Last Name:BJOTVEDT
Suffix:
Gender:M
Credentials:SOIDC (SO-ATP)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:409 RIDGEWAY DR
Mailing Address - Street 2:
Mailing Address - City:SNEADS FERRY
Mailing Address - State:NC
Mailing Address - Zip Code:28460-7613
Mailing Address - Country:US
Mailing Address - Phone:602-809-0298
Mailing Address - Fax:
Practice Address - Street 1:2D MARINE RAIDER BATTALION
Practice Address - Street 2:BATTALION AID STATION, PSC BOX 20183
Practice Address - City:CAMP LEJEUNE
Practice Address - State:NC
Practice Address - Zip Code:28542-0183
Practice Address - Country:US
Practice Address - Phone:910-440-7704
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-28
Last Update Date:2025-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC10243398HB1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman