Healthcare Provider Details

I. General information

NPI: 1194803338
Provider Name (Legal Business Name): SOUTHSIDE HEAD N NECK SURGERY PROFESSIONAL CORP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 07/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

930 SOUTH AVE. SUITE 4B
COLONIAL HEIGHTS VA
23834
US

IV. Provider business mailing address

930 SOUTH AVE. SUITE 4B
COLONIAL HEIGHTS VA
23834
US

V. Phone/Fax

Practice location:
  • Phone: 804-504-0530
  • Fax: 804-504-0532
Mailing address:
  • Phone: 804-504-0530
  • Fax: 804-504-0532

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number0101036702
License Number StateVA

VIII. Authorized Official

Name: DAVID CANGCUESTA
Title or Position: PHYSICIAN/OWNER
Credential: M.D.
Phone: 804-337-1110