Provider Demographics
NPI:1003312869
Name:GOLLUB, JOSHUA WAYNE
Entity Type:Individual
Prefix:
First Name:JOSHUA
Middle Name:WAYNE
Last Name:GOLLUB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CHILDRENS LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1910
Mailing Address - Country:US
Mailing Address - Phone:757-668-7249
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-02
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101272170208000000X, 2080P0204X, 2080N0001X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program