Provider Demographics
NPI:1629156039
Name:WESTERN TIDEWATER HEALTH DISTRICT
Entity Type:Organization
Organization Name:WESTERN TIDEWATER HEALTH DISTRICT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:DEMETRIA
Authorized Official - Middle Name:
Authorized Official - Last Name:LINDSAY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-686-4901
Mailing Address - Street 1:1217 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-4320
Mailing Address - Country:US
Mailing Address - Phone:757-686-4901
Mailing Address - Fax:757-925-2243
Practice Address - Street 1:1217 N MAIN ST
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-4320
Practice Address - Country:US
Practice Address - Phone:757-686-4901
Practice Address - Fax:757-925-2243
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA4972279Medicaid
VA497065Medicare ID - Type Unspecified