Healthcare Provider Details

I. General information

NPI: 1093177073
Provider Name (Legal Business Name): AREK HIDIRSAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2016
Last Update Date: 08/28/2023
Certification Date: 08/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR DEPT AYA
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

620 JOHN PAUL JONES CIR DEPT AYA
PORTSMOUTH VA
23708-2111
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-0167
  • Fax: 757-953-0058
Mailing address:
  • Phone: 757-953-0167
  • Fax: 757-953-0058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA162777
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number0101263112
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: