Provider Demographics
NPI:1811028152
Name:TIDEWATER ENDOCRINE CONSULTANTS, PC
Entity Type:Organization
Organization Name:TIDEWATER ENDOCRINE CONSULTANTS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DWIGHT
Authorized Official - Middle Name:FITZGERALD
Authorized Official - Last Name:MATTHIAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-436-0909
Mailing Address - Street 1:PO BOX 1345
Mailing Address - Street 2:
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23327-1345
Mailing Address - Country:US
Mailing Address - Phone:757-436-0909
Mailing Address - Fax:757-436-0168
Practice Address - Street 1:667 KINGSBOROUGH SQ
Practice Address - Street 2:SUITE 300
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-4999
Practice Address - Country:US
Practice Address - Phone:757-436-0909
Practice Address - Fax:757-436-0168
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101229098207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAH34088Medicare UPIN
VAC09226Medicare ID - Type Unspecified