Healthcare Provider Details

I. General information

NPI: 1720059900
Provider Name (Legal Business Name): JOHN M O'BANNON III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 01/26/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 FOREST AVE SUITE 300
RICHMOND VA
23226-3792
US

IV. Provider business mailing address

7301 FOREST AVE SUITE 302
RICHMOND VA
23226-3792
US

V. Phone/Fax

Practice location:
  • Phone: 804-288-2742
  • Fax: 804-288-9053
Mailing address:
  • Phone: 804-288-2767
  • Fax: 804-288-9897

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number0101025330
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: