Provider Demographics
NPI:1801900113
Name:HALIFAX ENDOCRINOLOGY AND OSTEOPOROSIS CENTER PC
Entity type:Organization
Organization Name:HALIFAX ENDOCRINOLOGY AND OSTEOPOROSIS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TESSIE
Authorized Official - Middle Name:
Authorized Official - Last Name:OTERO-TRUITT
Authorized Official - Suffix:
Authorized Official - Credentials:MD, FACP FACE
Authorized Official - Phone:434-575-5844
Mailing Address - Street 1:2232 WILBORN AVE
Mailing Address - Street 2:STE B
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:VA
Mailing Address - Zip Code:24592-1662
Mailing Address - Country:US
Mailing Address - Phone:434-575-5844
Mailing Address - Fax:434-575-0862
Practice Address - Street 1:2232 WILBORN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SOUTH BOSTON
Practice Address - State:VA
Practice Address - Zip Code:24592-1662
Practice Address - Country:US
Practice Address - Phone:434-575-5844
Practice Address - Fax:434-575-0862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101052342207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006082807Medicaid
VA44141OtherOPTIMA
VA281110OtherBCBS
VA44141OtherOPTIMA
VA460000015Medicare PIN