Provider Demographics
NPI:1700862588
Name:LETADA, PHILLIP R (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:R
Last Name:LETADA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7288 HANOVER GREEN DR
Mailing Address - Street 2:
Mailing Address - City:MECHANICSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:23111-1706
Mailing Address - Country:US
Mailing Address - Phone:757-822-0233
Mailing Address - Fax:
Practice Address - Street 1:17 MANHATTAN SQ
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5843
Practice Address - Country:US
Practice Address - Phone:757-838-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-22
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236866207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology