Healthcare Provider Details

I. General information

NPI: 1902901556
Provider Name (Legal Business Name): BRIAN WITTMUS ZAGOL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 11/06/2022
Certification Date: 11/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 EXECUTIVE DR
DANVILLE VA
24541-4100
US

IV. Provider business mailing address

201 S MAIN ST STE 1100
DANVILLE VA
24541-2938
US

V. Phone/Fax

Practice location:
  • Phone: 434-791-1088
  • Fax: 434-799-8525
Mailing address:
  • Phone: 434-791-1088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number0101234822
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number39369
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code207RI0011X
TaxonomyInterventional Cardiology Physician
License Number0101234822
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: