Healthcare Provider Details

I. General information

NPI: 1093070781
Provider Name (Legal Business Name): PENINSULA VASCULAR CENTER, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2012
Last Update Date: 07/09/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 BUTLER FARM RD SUITE B
HAMPTON VA
23666-1777
US

IV. Provider business mailing address

501 BUTLER FARM RD SUITE I
HAMPTON VA
23666-1777
US

V. Phone/Fax

Practice location:
  • Phone: 757-766-6080
  • Fax: 757-766-6085
Mailing address:
  • Phone: 757-766-6080
  • Fax: 757-766-6085

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: KHALIL B DAHDAH
Title or Position: MANAGING PARTNER
Credential: MD
Phone: 757-766-6080