Healthcare Provider Details

I. General information

NPI: 1215225297
Provider Name (Legal Business Name): TOM TOOTHAKER DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2011
Last Update Date: 07/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 NAT TURNER BLVD S
NEWPORT NEWS VA
23606-2899
US

IV. Provider business mailing address

250 NAT TURNER BLVD S
NEWPORT NEWS VA
23606-2899
US

V. Phone/Fax

Practice location:
  • Phone: 757-596-1900
  • Fax: 866-420-0168
Mailing address:
  • Phone: 757-596-1900
  • Fax: 866-420-0168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305206988
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: