Provider Demographics
NPI:1811189772
Name:BERTOLINO, SIOBHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:SIOBHAN
Middle Name:
Last Name:BERTOLINO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:844 KEMPSVILLE RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-3927
Mailing Address - Country:US
Mailing Address - Phone:757-461-3890
Mailing Address - Fax:757-461-0836
Practice Address - Street 1:844 KEMPSVILLE RD
Practice Address - Street 2:SUITE 208
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23502-3927
Practice Address - Country:US
Practice Address - Phone:757-461-3890
Practice Address - Fax:757-461-0836
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2011-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101249427174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAVV2625AMedicare PIN