Healthcare Provider Details

I. General information

NPI: 1023094950
Provider Name (Legal Business Name): WILSON PARRISH DAUGHERTY M.D., PH. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 10/10/2024
Certification Date: 10/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 RIVERVIEW AVE STE 202A
NORFOLK VA
23510-1065
US

IV. Provider business mailing address

301 RIVERVIEW AVE STE 202A
NORFOLK VA
23510-1065
US

V. Phone/Fax

Practice location:
  • Phone: 757-252-9140
  • Fax: 757-793-4149
Mailing address:
  • Phone: 757-252-9140
  • Fax: 757-793-4149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number0101259100
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2011-01173
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: