Provider Demographics
NPI:1205832979
Name:FENDERSON, ALLEN R (MD)
Entity Type:Individual
Prefix:
First Name:ALLEN
Middle Name:R
Last Name:FENDERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:860 OMNI BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4430
Mailing Address - Country:US
Mailing Address - Phone:757-232-8769
Mailing Address - Fax:757-232-8875
Practice Address - Street 1:351 EDWIN DR
Practice Address - Street 2:STE 102
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-4559
Practice Address - Country:US
Practice Address - Phone:757-499-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027355207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010014832Medicaid
VA462019OtherANTHEM
VAP00137845OtherRAILROAD MEDICARE
VAB08329Medicare UPIN
VA082951514Medicare ID - Type Unspecified