Provider Demographics
NPI:1740256387
Name:HEATWOLE, KATHARINE W (MD)
Entity type:Individual
Prefix:DR
First Name:KATHARINE
Middle Name:W
Last Name:HEATWOLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:596 LYNNHAVEN PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23452-7371
Mailing Address - Country:US
Mailing Address - Phone:757-802-4500
Mailing Address - Fax:757-226-9002
Practice Address - Street 1:596 LYNNHAVEN PKWY STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23452-7371
Practice Address - Country:US
Practice Address - Phone:757-802-4500
Practice Address - Fax:757-226-9002
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01010463832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010111862Medicaid
VA010111862Medicaid
006088S33Medicare ID - Type Unspecified