Healthcare Provider Details

I. General information

NPI: 1154324879
Provider Name (Legal Business Name): SAMUEL WINFRED PERSON D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date: 03/17/2006
Reactivation Date: 03/22/2006

III. Provider practice location address

2020 WAKEFIELD AVE
PETERSBURG VA
23805-2112
US

IV. Provider business mailing address

2020 WAKEFIELD AVE
PETERSBURG VA
23805-2112
US

V. Phone/Fax

Practice location:
  • Phone: 804-732-1211
  • Fax: 804-733-5946
Mailing address:
  • Phone: 804-732-1211
  • Fax: 804-733-5946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number0103000377
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: