Provider Demographics
NPI:1780805077
Name:ZHAO, JUN
Entity type:Individual
Prefix:
First Name:JUN
Middle Name:
Last Name:ZHAO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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 1:12200 WARWICK BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23601-2344
Practice Address - Country:US
Practice Address - Phone:757-534-5100
Practice Address - Fax:757-534-5395
Is Sole Proprietor?:No
Enumeration Date:2007-05-02
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012520122084N0400X
FLME1415132084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1780805077Medicaid
VAP01085404Medicare PIN
VA1780805077Medicaid