Healthcare Provider Details

I. General information

NPI: 1356542922
Provider Name (Legal Business Name): TIDEWATER PODIATRY GROUP LTD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2007
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6161 KEMPSVILLE CIR STE 230
NORFOLK VA
23502-3932
US

IV. Provider business mailing address

6161 KEMPSVILLE CIR STE 230
NORFOLK VA
23502-3932
US

V. Phone/Fax

Practice location:
  • Phone: 757-481-6248
  • Fax:
Mailing address:
  • Phone: 757-481-6248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number StateVA

VIII. Authorized Official

Name: DR. JAY TISCHLER
Title or Position: PRESIDENT
Credential: DPM
Phone: 757-481-6248