Provider Demographics
NPI:1740341841
Name:HACKELTON, KARISSA L (MD)
Entity type:Individual
Prefix:
First Name:KARISSA
Middle Name:L
Last Name:HACKELTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 GLENSIDE DR
Mailing Address - Street 2:SUITE 105
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-3769
Mailing Address - Country:US
Mailing Address - Phone:804-288-0399
Mailing Address - Fax:804-285-0088
Practice Address - Street 1:1800 GLENSIDE DR
Practice Address - Street 2:SUITE 110
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-3769
Practice Address - Country:US
Practice Address - Phone:804-288-1800
Practice Address - Fax:804-288-0515
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2011-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101236653207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740341841Medicaid
VA1740341841Medicaid
P00817416Medicare PIN
VA022713V12Medicare PIN