Healthcare Provider Details

I. General information

NPI: 1396063855
Provider Name (Legal Business Name): DAVID JOSEPH PERILLO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2010
Last Update Date: 09/29/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

347 LAND OR DR
RUTHER GLEN VA
22546-1235
US

IV. Provider business mailing address

347 LAND OR DR
RUTHER GLEN VA
22546-1235
US

V. Phone/Fax

Practice location:
  • Phone: 919-801-0792
  • Fax:
Mailing address:
  • Phone: 919-801-0792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number0103301030
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: