Provider Demographics
NPI:1508055591
Name:IRVING S GOTTFRIED MD PC
Entity Type:Organization
Organization Name:IRVING S GOTTFRIED MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:IRVING
Authorized Official - Middle Name:SASS
Authorized Official - Last Name:GOTTFRIED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:434-392-6877
Mailing Address - Street 1:800 OAK ST
Mailing Address - Street 2:SUITE 2-105
Mailing Address - City:FARMVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23901-1199
Mailing Address - Country:US
Mailing Address - Phone:434-392-6877
Mailing Address - Fax:434-392-8809
Practice Address - Street 1:800 OAK ST
Practice Address - Street 2:SUITE 2-105
Practice Address - City:FARMVILLE
Practice Address - State:VA
Practice Address - Zip Code:23901-1199
Practice Address - Country:US
Practice Address - Phone:434-392-6877
Practice Address - Fax:434-392-8809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-16
Last Update Date:2007-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101039536174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6046258Medicaid
VA042514OtherANTHEM BC/BS
VA1000013150OtherMEDICARE RAILROAD
VA53907OtherSENTARA
VA1000013150OtherMEDICARE RAILROAD