Healthcare Provider Details

I. General information

NPI: 1831176296
Provider Name (Legal Business Name): DAVID LEE TOLLIVER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/28/2005
Last Update Date: 09/04/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 HUFFARD DR
BLUEFIELD VA
24605-9209
US

IV. Provider business mailing address

110 HUFFARD DR
BLUEFIELD VA
24605-9209
US

V. Phone/Fax

Practice location:
  • Phone: 276-326-3376
  • Fax: 276-326-3046
Mailing address:
  • Phone: 276-326-3376
  • Fax: 276-326-3046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number0102050026
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: