Healthcare Provider Details

I. General information

NPI: 1821319567
Provider Name (Legal Business Name): DPMPERILLONRVA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/17/2010
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: DAVID J PERILLO
Title or Position: OWNER
Credential: DPM
Phone: 919-801-0792