Healthcare Provider Details

I. General information

NPI: 1891141768
Provider Name (Legal Business Name): MR. ITSE BEGHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2016
Last Update Date: 05/06/2020
Certification Date: 05/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1721 ADMIRAL TAUSSIG BLVD
NORFOLK VA
23511-2802
US

IV. Provider business mailing address

1600 GRADY AVE APT 108
CHARLOTTESVILLE VA
22903-1905
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-8859
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: