Provider Demographics
NPI:1740743053
Name:OWENS, JEREMY (MD)
Entity type:Individual
Prefix:DR
First Name:JEREMY
Middle Name:
Last Name:OWENS
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 1:1828 DUKE OF NORFOLK QUAY
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454-1106
Mailing Address - Country:US
Mailing Address - Phone:757-572-6052
Mailing Address - Fax:
Practice Address - Street 1:4534 BONNEY RD STE B
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23462-3873
Practice Address - Country:US
Practice Address - Phone:757-499-4101
Practice Address - Fax:757-260-7352
Is Sole Proprietor?:No
Enumeration Date:2019-04-12
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101282801207K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1740743053Medicaid