Provider Demographics
NPI:1407822604
Name:JESSUP, DOUGLAS E (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:E
Last Name:JESSUP
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1115 BOULDERS PKWY
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NORTH CHESTERFIELD
Mailing Address - State:VA
Mailing Address - Zip Code:23225-4067
Mailing Address - Country:US
Mailing Address - Phone:804-560-5595
Mailing Address - Fax:804-560-9029
Practice Address - Street 1:7858 SHRADER RD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23294
Practice Address - Country:US
Practice Address - Phone:804-270-1305
Practice Address - Fax:804-273-9294
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101036486207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6496059Medicaid
B08409Medicare UPIN
VA6496059Medicaid