Provider Demographics
NPI:1184673295
Name:TACASTACAS, JOSELIN D (MD)
Entity Type:Individual
Prefix:
First Name:JOSELIN
Middle Name:D
Last Name:TACASTACAS
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 1:11844 ROCK LANDING DR STE B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4206
Mailing Address - Country:US
Mailing Address - Phone:757-873-0161
Mailing Address - Fax:757-873-0205
Practice Address - Street 1:475 MCLAWS CIR STE 1
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:VA
Practice Address - Zip Code:23185
Practice Address - Country:US
Practice Address - Phone:757-259-9466
Practice Address - Fax:757-259-7907
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010236219207R00000X
ORMD28115207R00000X
VA0101236219207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010110866Medicaid
VA177346OtherBLUE CROSS
VA010110831Medicaid
VA010158192Medicaid
010087000OtherFEDERAL BLACK LUNG
VAVA0105OtherJOHN DEERE
010087000OtherFEDERAL BLACK LUNG
C08117Medicare ID - Type Unspecified
VA010110866Medicaid