Provider Demographics
NPI:1720084957
Name:POWELL, DAVID M (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:M
Last Name:POWELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 LAKE WRIGHT DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23502-1871
Mailing Address - Country:US
Mailing Address - Phone:757-213-5700
Mailing Address - Fax:757-213-5701
Practice Address - Street 1:3000 COLISEUM DR
Practice Address - Street 2:SUITE 104
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-5963
Practice Address - Country:US
Practice Address - Phone:757-827-9400
Practice Address - Fax:757-827-9320
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101051961174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA53131OtherOPTIMA
VA53131OtherOPTIMA