Healthcare Provider Details

I. General information

NPI: 1497823728
Provider Name (Legal Business Name): INTERNAL MEDICINE KIDNEY & HYPERTENSION CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 06/18/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5700 LAKE WRIGHT DR STE 101
NORFOLK VA
23502-1859
US

IV. Provider business mailing address

5700 LAKE WRIGHT DR STE 101
NORFOLK VA
23502-1859
US

V. Phone/Fax

Practice location:
  • Phone: 757-502-4840
  • Fax: 757-502-4841
Mailing address:
  • Phone: 757-502-4840
  • Fax: 757-502-4841

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number0101024987
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number0101024987
License Number StateVA

VIII. Authorized Official

Name: DR. HUMBERTO F. PAVON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 757-502-4840