Provider Demographics
NPI:1457745143
Name:NORTH, DWAYNE
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:NORTH
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 1:856 J CLYDE MORRIS BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:757-316-5800
Mailing Address - Fax:757-534-5190
Practice Address - Street 1:7554 HOSPITAL DR STE D303
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-4178
Practice Address - Country:US
Practice Address - Phone:804-693-3400
Practice Address - Fax:804-693-9793
Is Sole Proprietor?:No
Enumeration Date:2015-03-20
Last Update Date:2020-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
VA0102206030208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program