Healthcare Provider Details

I. General information

NPI: 1174636377
Provider Name (Legal Business Name): KEVIN KEITH WOISARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 COLISEUM DR SENTARA CAREPLEX HOSPITAL
HAMPTON VA
23666
US

IV. Provider business mailing address

PO BOX 12127
NEWPORT NEWS VA
23612-2127
US

V. Phone/Fax

Practice location:
  • Phone: 757-736-1621
  • Fax: 757-827-6748
Mailing address:
  • Phone: 757-867-6101
  • Fax: 757-867-6587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0101044647
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: