Healthcare Provider Details

I. General information

NPI: 1932763927
Provider Name (Legal Business Name): MICHAEL JORDAN BRASSELL DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2019
Last Update Date: 02/16/2026
Certification Date: 02/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

730 THIMBLE SHOALS BLVD STE 130
NEWPORT NEWS VA
23606-4562
US

IV. Provider business mailing address

730 THIMBLE SHOALS BLVD STE 130
NEWPORT NEWS VA
23606-4562
US

V. Phone/Fax

Practice location:
  • Phone: 757-873-1554
  • Fax:
Mailing address:
  • Phone: 757-873-1554
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number0103301346
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number0103301346
License Number StateVA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301346
License Number StateVA
# 4
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0103301346
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: