Healthcare Provider Details

I. General information

NPI: 1578125381
Provider Name (Legal Business Name): VINCENT EDOUARD RETARDO GULLAS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2019
Last Update Date: 07/19/2022
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 J CLYDE MORRIS BLVD
NEWPORT NEWS VA
23601-1929
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: 757-594-3580
  • Fax:
Mailing address:
  • Phone: 757-316-5800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number125073772
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number0101274265
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: