Healthcare Provider Details

I. General information

NPI: 1639599723
Provider Name (Legal Business Name): TIDEWATER ENDOCRINOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 06/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3205 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5205
US

IV. Provider business mailing address

3205 CHURCHLAND BLVD
CHESAPEAKE VA
23321-5205
US

V. Phone/Fax

Practice location:
  • Phone: 757-484-7822
  • Fax: 757-484-7362
Mailing address:
  • Phone: 757-484-7822
  • Fax: 757-484-7362

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0101034393
License Number StateVA

VIII. Authorized Official

Name: DR. JAMES CALVIN LAROCQUE
Title or Position: OWNER
Credential: M.D.
Phone: 757-484-7822