Provider Demographics
NPI:1134876337
Name:TIDEWATERHEALTH360 PLLC
Entity type:Organization
Organization Name:TIDEWATERHEALTH360 PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CORPIN
Authorized Official - Last Name:CAJES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:757-376-8460
Mailing Address - Street 1:324 SAGE RD
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23456-4419
Mailing Address - Country:US
Mailing Address - Phone:757-376-8460
Mailing Address - Fax:
Practice Address - Street 1:1081 KEMPSVILLE RD
Practice Address - Street 2:
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-8126
Practice Address - Country:US
Practice Address - Phone:757-376-8460
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-07
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty