Provider Demographics
NPI:1467579482
Name:TIDEWATER MEDICAL CLINIC PC
Entity Type:Organization
Organization Name:TIDEWATER MEDICAL CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:G
Authorized Official - Last Name:CARPIO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-549-9671
Mailing Address - Street 1:111 COASTAL WAY
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-4603
Mailing Address - Country:US
Mailing Address - Phone:757-549-9671
Mailing Address - Fax:757-549-6802
Practice Address - Street 1:111 COASTAL WAY
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4603
Practice Address - Country:US
Practice Address - Phone:757-549-9671
Practice Address - Fax:757-549-6802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101055402207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAG45943Medicare UPIN