Healthcare Provider Details

I. General information

NPI: 1497997712
Provider Name (Legal Business Name): GIOVANNI DISANDRO JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/01/2009
Last Update Date: 03/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

885 KEMPSVILLE RD STE 101
NORFOLK VA
23502-3800
US

IV. Provider business mailing address

885 KEMPSVILLE ROAD SUITE 101
NORFOLK VA
23502-3800
US

V. Phone/Fax

Practice location:
  • Phone: 757-461-1444
  • Fax: 757-461-8238
Mailing address:
  • Phone: 757-461-1444
  • Fax: 757-461-8238

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number0101254154
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number0101254154
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: