1386679967 NPI number — WILLIAM L OLD III MD

Table of content: WILLIAM L OLD III MD (NPI 1386679967)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386679967 NPI number — WILLIAM L OLD III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
OLD
Provider First Name:
WILLIAM
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386679967
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
856 J CLYDE MORRIS BLVD
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
NEWPORT NEWS
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23601-1318
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-594-4006
Provider Business Mailing Address Fax Number:
757-594-2195

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
500 J CLYDE MORRIS BLVD
Provider Second Line Business Practice Location Address:
STE 602
Provider Business Practice Location Address City Name:
NEWPORT NEWS
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23601-1929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-534-5511
Provider Business Practice Location Address Fax Number:
757-534-5515
Provider Enumeration Date:
07/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208G00000X , with the licence number:  0101035691 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00360212 . This is a "RAILROAD" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 1386679967 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 010285216 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com