Healthcare Provider Details

I. General information

NPI: 1376710715
Provider Name (Legal Business Name): COMMONWEALTH PEDIATRICS PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 CLAIRMONT COURT SUITE 211
COLONIAL HEIGHTS VA
23834
US

IV. Provider business mailing address

430 CLAIRMONT COURT SUITE 211
COLONIAL HEIGHTS VA
23834
US

V. Phone/Fax

Practice location:
  • Phone: 804-526-0346
  • Fax: 804-526-7675
Mailing address:
  • Phone: 804-526-0346
  • Fax: 804-526-7675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101057140
License Number StateVA

VIII. Authorized Official

Name: ROLANDA MCDONALD-JOHNSON
Title or Position: PRESIDENT
Credential: MD
Phone: 804-526-0346