Provider Demographics
NPI:1891137048
Name:TIDEWATER FOOT CENTER LLC
Entity Type:Organization
Organization Name:TIDEWATER FOOT CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:THOU
Authorized Official - Last Name:PRAK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-597-7699
Mailing Address - Street 1:11747 JEFFERSON AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4402
Mailing Address - Country:US
Mailing Address - Phone:757-597-7699
Mailing Address - Fax:757-597-7099
Practice Address - Street 1:126 MONARCH DR
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23602-6884
Practice Address - Country:US
Practice Address - Phone:757-597-1520
Practice Address - Fax:757-597-7099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-29
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103301081213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty