Provider Demographics
NPI:1093070781
Name:PENINSULA VASCULAR CENTER, P.C.
Entity Type:Organization
Organization Name:PENINSULA VASCULAR CENTER, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:KHALIL
Authorized Official - Middle Name:B
Authorized Official - Last Name:DAHDAH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-766-6080
Mailing Address - Street 1:501 BUTLER FARM RD
Mailing Address - Street 2:SUITE I
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1777
Mailing Address - Country:US
Mailing Address - Phone:757-766-6080
Mailing Address - Fax:757-766-6085
Practice Address - Street 1:501 BUTLER FARM RD
Practice Address - Street 2:SUITE B
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1777
Practice Address - Country:US
Practice Address - Phone:757-766-6080
Practice Address - Fax:757-766-6085
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-09
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional RadiologyGroup - Multi-Specialty
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty