Provider Demographics
NPI:1265660203
Name:MANOUILOV, CHARYSSE JOHNSTON (MD)
Entity Type:Individual
Prefix:
First Name:CHARYSSE
Middle Name:JOHNSTON
Last Name:MANOUILOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARYSSE
Other - Middle Name:MERRITT
Other - Last Name:JOHSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1181 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-2437
Mailing Address - Country:US
Mailing Address - Phone:757-425-1600
Mailing Address - Fax:757-425-6495
Practice Address - Street 1:1181 FIRST COLONIAL RD
Practice Address - Street 2:SUITE 200
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-2437
Practice Address - Country:US
Practice Address - Phone:757-425-1600
Practice Address - Fax:757-425-6495
Is Sole Proprietor?:No
Enumeration Date:2009-06-29
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101254280207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0101254280OtherLICENSE