Healthcare Provider Details

I. General information

NPI: 1104872019
Provider Name (Legal Business Name): MARK MILITANA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 SOUTH ADAMS STREET
PETERSBURG VA
23803
US

IV. Provider business mailing address

1101 W FRANKLIN ST
RICHMOND VA
23220-3709
US

V. Phone/Fax

Practice location:
  • Phone: 804-862-5680
  • Fax: 804-862-5698
Mailing address:
  • Phone: 804-370-3082
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101045615
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2014-02252
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: