Healthcare Provider Details

I. General information

NPI: 1770283590
Provider Name (Legal Business Name): JONATHAN HENRY DESIMONE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2023
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

IV. Provider business mailing address

77 NEALY AVE
LANGLEY AFB VA
23665-2040
US

V. Phone/Fax

Practice location:
  • Phone: 757-764-0770
  • Fax: 757-764-2395
Mailing address:
  • Phone: 757-764-0770
  • Fax: 757-764-2395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number34.017401
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number34.017401
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0102210071
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: