Healthcare Provider Details

I. General information

NPI: 1528052115
Provider Name (Legal Business Name): MITCHELL R WASKIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 11/28/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 JOHNSTON WILLIS DR
RICHMOND VA
23235-4730
US

IV. Provider business mailing address

1465 JOHNSTON WILLIS DR
RICHMOND VA
23235-4730
US

V. Phone/Fax

Practice location:
  • Phone: 804-320-3668
  • Fax: 804-320-2600
Mailing address:
  • Phone: 804-320-3668
  • Fax: 804-320-2600

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0103000676
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: