Healthcare Provider Details

I. General information

NPI: 1831184803
Provider Name (Legal Business Name): ALFRED W. O'DAIRE JR. PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 BELFIELD DR.
EMPORIA VA
23847
US

IV. Provider business mailing address

511 BELFIELD DR.
EMPORIA VA
23847
US

V. Phone/Fax

Practice location:
  • Phone: 434-348-4680
  • Fax: 434-336-0014
Mailing address:
  • Phone: 434-348-4680
  • Fax: 434-336-0014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0110840276
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: