Healthcare Provider Details

I. General information

NPI: 1629016654
Provider Name (Legal Business Name): ISAM T ZIBDEH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 03/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

102 15TH ST NW SUITE 301
NORTON VA
24273-1616
US

IV. Provider business mailing address

102 15TH ST NW SUITE 301
NORTON VA
24273-1616
US

V. Phone/Fax

Practice location:
  • Phone: 276-679-1624
  • Fax: 276-679-6011
Mailing address:
  • Phone: 276-679-1624
  • Fax: 276-679-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101029808
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: