Healthcare Provider Details

I. General information

NPI: 1487826392
Provider Name (Legal Business Name): JUSTIN MATTHEW RODEBAUGH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2008
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 GRESHAM DR
NORFOLK VA
23507-1904
US

IV. Provider business mailing address

5428 CLUB HEAD RD
VIRGINIA BEACH VA
23455-6809
US

V. Phone/Fax

Practice location:
  • Phone: 440-596-2138
  • Fax:
Mailing address:
  • Phone: 757-499-5428
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116030112
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number4301118943
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: