Provider Demographics
NPI:1053558981
Name:TIDEWATER MEDICAL CARE PC
Entity type:Organization
Organization Name:TIDEWATER MEDICAL CARE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MIGDONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:MONTEJO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-965-9465
Mailing Address - Street 1:4608 THOROUGHGOOD DRIVE
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23455
Mailing Address - Country:US
Mailing Address - Phone:757-965-9465
Mailing Address - Fax:757-965-9491
Practice Address - Street 1:4608 THOROUGHGOOD DRIVE
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455
Practice Address - Country:US
Practice Address - Phone:757-965-9465
Practice Address - Fax:757-965-9491
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-01-14
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101058505207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA022057T53Medicare PIN
VA022225T53Medicare PIN
VA00Y060T02Medicare PIN
VAG74678Medicare UPIN
VAG90778Medicare UPIN
VA00Y060T03Medicare PIN
VA021663T53Medicare PIN
VA020738T53Medicare PIN
VA00Y060T01Medicare PIN
VAC10753Medicare PIN
VA021208T58Medicare PIN
VA020744T53Medicare PIN