Healthcare Provider Details

I. General information

NPI: 1407822604
Provider Name (Legal Business Name): DOUGLAS E JESSUP MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 12/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7858 SHRADER RD
RICHMOND VA
23294
US

IV. Provider business mailing address

1115 BOULDERS PKWY SUITE 200
NORTH CHESTERFIELD VA
23225-4067
US

V. Phone/Fax

Practice location:
  • Phone: 804-270-1305
  • Fax: 804-273-9294
Mailing address:
  • Phone: 804-560-5595
  • Fax: 804-560-9029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number0101036486
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code207XS0114X
TaxonomyAdult Reconstructive Orthopaedic Surgery Physician
License Number0101036486
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: