Provider Demographics
NPI:1245859727
Name:PRIVOTT, MICHAEL I
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:I
Last Name:PRIVOTT
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 1:999 WATERSIDE DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-3300
Mailing Address - Country:US
Mailing Address - Phone:757-589-4097
Mailing Address - Fax:
Practice Address - Street 1:999 WATERSIDE DR
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-3300
Practice Address - Country:US
Practice Address - Phone:757-589-4097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-14
Last Update Date:2020-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty