Provider Demographics
NPI:1164859930
Name:BERTOLASIO, BARRY (IDC)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:BERTOLASIO
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:835 CRASHAW ST
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-6913
Mailing Address - Country:US
Mailing Address - Phone:757-288-5747
Mailing Address - Fax:
Practice Address - Street 1:1840 GATOR BLVD
Practice Address - Street 2:BUILDING 3841
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8931
Practice Address - Country:US
Practice Address - Phone:757-763-3321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-10-10
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman