Provider Demographics
NPI:1740268853
Name:PRILLAMAN, HENRY MENTON (MD)
Entity type:Individual
Prefix:
First Name:HENRY
Middle Name:MENTON
Last Name:PRILLAMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:856 J CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23601-1318
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11848 ROCK LANDING DR
Practice Address - Street 2:SUITE 402
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-4425
Practice Address - Country:US
Practice Address - Phone:757-873-1374
Practice Address - Fax:757-466-1312
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2014-02-18
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Provider Licenses
StateLicense IDTaxonomies
VA0202057231208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740268853Medicaid
VAP00432367Medicare PIN
G70693Medicare UPIN
VA015262R53Medicare PIN