Healthcare Provider Details

I. General information

NPI: 1386908358
Provider Name (Legal Business Name): JOHN RUSSELL BARLEY IV D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2012
Last Update Date: 11/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12200 WARWICK BLVD SUITE 310
NEWPORT NEWS VA
23601-2344
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 757-534-9988
  • Fax: 757-534-5688
Mailing address:
  • Phone: 757-316-5960
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number0102203634
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number0102203634
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: