Provider Demographics
NPI:1003833757
Name:WADSWORTH, MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:MICHELE
Middle Name:
Last Name:WADSWORTH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2117 MCCOMAS WAY
Mailing Address - Street 2:STE. 103
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-3908
Mailing Address - Country:US
Mailing Address - Phone:757-668-6715
Mailing Address - Fax:757-668-6680
Practice Address - Street 1:2117 MCCOMAS WAY
Practice Address - Street 2:STE. 103
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23456-3908
Practice Address - Country:US
Practice Address - Phone:757-668-6715
Practice Address - Fax:757-668-6680
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101049021208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA5417787860686EOtherCIGNA
NC890618KMedicaid
VA237158OtherANTHEM BCBS,HK,HK,FAMIS
VA637669OtherALLIANCE,MAMSI,MDIPA,
NC541778786OtherNC HEALTH CH
VA6739784Medicaid
VA35381OtherOPTIMA,FAMILY CARE,FAMIS
VA637669OtherALLIANCE,MAMSI,MDIPA,