Provider Demographics
NPI:1275954349
Name:COLONIAL HEIGHTS PEDIATRICS
Entity Type:Organization
Organization Name:COLONIAL HEIGHTS PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JAWED
Authorized Official - Middle Name:
Authorized Official - Last Name:IQBAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:804-536-1332
Mailing Address - Street 1:16011 KAIROS RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SOUTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23834-5207
Mailing Address - Country:US
Mailing Address - Phone:804-520-2600
Mailing Address - Fax:804-520-5853
Practice Address - Street 1:16011 KAIROS RD
Practice Address - Street 2:SUITE 100
Practice Address - City:SOUTH CHESTERFIELD
Practice Address - State:VA
Practice Address - Zip Code:23834-5207
Practice Address - Country:US
Practice Address - Phone:804-520-2600
Practice Address - Fax:804-520-5853
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-17
Last Update Date:2013-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA010156547208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA672282Medicaid