Provider Demographics
NPI:1407253503
Name:ATLANTIC FAMILY MEDICINE
Entity Type:Organization
Organization Name:ATLANTIC FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:RYAN
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-493-1965
Mailing Address - Street 1:837 FIRST COLONIAL RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-6195
Mailing Address - Country:US
Mailing Address - Phone:757-493-1965
Mailing Address - Fax:757-544-9873
Practice Address - Street 1:837 FIRST COLONIAL RD
Practice Address - Street 2:SUITE B
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-6195
Practice Address - Country:US
Practice Address - Phone:757-493-1965
Practice Address - Fax:757-544-9873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-04
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101239405207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC133920Medicare UPIN