Provider Demographics
NPI:1922427608
Name:WITHERIDGE, DAVID GLENN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GLENN
Last Name:WITHERIDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1250 E. MARSHALL ST
Mailing Address - Street 2:BOX 980509
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23298
Mailing Address - Country:US
Mailing Address - Phone:804-828-8786
Mailing Address - Fax:804-828-5466
Practice Address - Street 1:1250 E. MARSHALL ST
Practice Address - Street 2:BOX 980509
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298
Practice Address - Country:US
Practice Address - Phone:804-828-8786
Practice Address - Fax:804-828-5466
Is Sole Proprietor?:No
Enumeration Date:2014-04-10
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program