Provider Demographics
NPI:1659623205
Name:OLD DOMINION OSTEOPATHIC MEDICINE
Entity Type:Organization
Organization Name:OLD DOMINION OSTEOPATHIC MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:
Authorized Official - Last Name:SNEED
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:703-505-2620
Mailing Address - Street 1:2525 COWAN BLVD
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22401-8440
Mailing Address - Country:US
Mailing Address - Phone:540-423-6858
Mailing Address - Fax:
Practice Address - Street 1:2525 COWAN BLVD
Practice Address - Street 2:
Practice Address - City:FREDERICKSBURG
Practice Address - State:VA
Practice Address - Zip Code:22401-8440
Practice Address - Country:US
Practice Address - Phone:540-423-6858
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-05
Last Update Date:2013-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0102202984204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMMGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC038Medicare PIN