Healthcare Provider Details

I. General information

NPI: 1770736803
Provider Name (Legal Business Name): JEFFREY SCOTT LEWCZYK COTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JEFFREY SCOTT LEWCZYK COTA

II. Dates (important events)

Enumeration Date: 11/03/2008
Last Update Date: 11/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6808 IVANHOE CT
SUFFOLK VA
23435-3062
US

IV. Provider business mailing address

6808 IVANHOE CT
SUFFOLK VA
23435-3062
US

V. Phone/Fax

Practice location:
  • Phone: 757-483-2630
  • Fax:
Mailing address:
  • Phone: 757-483-2630
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number978721
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: