Healthcare Provider Details

I. General information

NPI: 1164702130
Provider Name (Legal Business Name): DANIEL TSUKANOV DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

IV. Provider business mailing address

1201 BROAD ROCK BLVD
RICHMOND VA
23249-0001
US

V. Phone/Fax

Practice location:
  • Phone: 804-675-5188
  • Fax:
Mailing address:
  • Phone: 804-675-5188
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number0102204113
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number0102204113
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: