Healthcare Provider Details

I. General information

NPI: 1053629535
Provider Name (Legal Business Name): JONATHAN MICHAEL SARDINA D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2010
Last Update Date: 10/07/2022
Certification Date: 10/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7547 MEDICAL DR STE 2200
GLOUCESTER VA
23061-4351
US

IV. Provider business mailing address

856 J CLYDE MORRIS BLVD STE A
NEWPORT NEWS VA
23601-1318
US

V. Phone/Fax

Practice location:
  • Phone: 804-693-2720
  • Fax:
Mailing address:
  • Phone: 757-316-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0102203248
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: