Healthcare Provider Details

I. General information

NPI: 1821032004
Provider Name (Legal Business Name): JOSE M DEJESUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 BENNETTS CREEK LNDG
SUFFOLK VA
23435-1749
US

IV. Provider business mailing address

125 BENNETTS CREEK LNDG
SUFFOLK VA
23435-1749
US

V. Phone/Fax

Practice location:
  • Phone: 757-312-6800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number44325
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: