Provider Demographics
NPI:1952611568
Name:ADVANCED PODIATRY OF HAMPTON ROADS
Entity Type:Organization
Organization Name:ADVANCED PODIATRY OF HAMPTON ROADS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:REX
Authorized Official - Middle Name:G
Authorized Official - Last Name:DIAZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:757-673-8562
Mailing Address - Street 1:612 KINGSBOROUGH SQUARE
Mailing Address - Street 2:SUITE 202
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320
Mailing Address - Country:US
Mailing Address - Phone:757-673-8562
Mailing Address - Fax:757-673-8174
Practice Address - Street 1:612 KINGSBOROUGH SQUARE
Practice Address - Street 2:SUITE 202
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320
Practice Address - Country:US
Practice Address - Phone:757-673-8562
Practice Address - Fax:757-673-8174
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-15
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0103300814213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty