Provider Demographics
NPI:1790953149
Name:JAMES M DESIMONE
Entity Type:Organization
Organization Name:JAMES M DESIMONE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:757-483-7706
Mailing Address - Street 1:422 GARRISONVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:GARRISONVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22554
Mailing Address - Country:US
Mailing Address - Phone:757-483-7706
Mailing Address - Fax:
Practice Address - Street 1:7015 E MANCHESTER BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22310
Practice Address - Country:US
Practice Address - Phone:757-483-7706
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-19
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
491066Medicare Oscar/Certification